ICU Emergencies Simulation Curriculum for Critical Care Fellows: Neurologic Emergencies

INTRODUCTION

The management of neurologic emergencies is an important component of critical care fellowship training. Additional training in neurocritical care has been demonstrated to improve clinical outcomes, though exposure to these emergencies during training can be limited.

METHODS

Three simulation cases are presented as part of a comprehensive neurologic emergencies curriculum for critical care trainees. The cases represent neurologic catastrophes encountered in the intensive care unit consisting of symptomatic hyponatremia, severe alcohol withdrawal syndrome, and brain herniation syndrome. The case descriptions are complete with learning objectives, critical actions checklists, and debriefing material for facilitators, as well as all necessary personnel briefs and required equipment.

RESULTS

The scenarios were completed over the course of the 2016-2017 academic year by first-year critical care fellows. Following curriculum implementation, there was an improvement in self-perceived confidence of fellows in neurologic emergency management skills.

DISCUSSION

The cases were felt to be realistic and beneficial and led to perceived improvement in management of neurologic emergencies and leadership during clinical crises.

Correlation Between mMINDS and CIWA-Ar Scoring Tools in Patients With Alcohol Withdrawal Syndrome

BACKGROUND

Many alcohol withdrawal scoring tools are used in hospitalized patients to assess the severity of alcohol withdrawal and guide treatment. The revised Clinical Institute Withdrawal Assessment (CIWA-Ar) and the modified Minnesota Detoxification Scale (mMINDS) are commonly used but have never been correlated.

OBJECTIVE

To determine the strength of correlation between the CIWA-Ar and mMINDS scoring tools in patients with alcohol withdrawal syndrome.

METHODS

A single-center, prospective correlation study conducted at a large academic medical center. Patients treated for alcohol withdrawal syndrome according to the Yale Alcohol Withdrawal Protocol were identified daily, and both the CIWA-Ar and mMINDS were administered at each time point required by the protocol. Clinical data were obtained from the electronic medical records.

RESULTS

A total of 185 CIWA-Ar and mMINDS scores were collected in 30 patients. The Pearson correlation coefficient across all scores was 0.82, indicating a strong correlation. The Pearson correlation coefficient was 0.87 for CIWA-Ar scores of 10 or less and 0.52 for CIWA-Ar scores above 10. Strong correlations were also shown for tremor (0.98), agitation (0.84), and orientation (0.87).

CONCLUSIONS

The correlation between the CIWA-Ar and mMINDS tools is strong and appears to be most robust in patients with CIWA-Ar scores of 10 or less.

ACG Clinical Guideline: Alcoholic Liver Disease

Alcoholic liver disease (ALD) comprises a clinical-histologic spectrum including fatty liver, alcoholic hepatitis (AH), and cirrhosis with its complications. Most patients are diagnosed at advanced stages and data on the prevalence and profile of patients with early disease are limited. Diagnosis of ALD requires documentation of chronic heavy alcohol use and exclusion of other causes of liver disease. Prolonged abstinence is the most effective strategy to prevent disease progression. AH presents with rapid onset or worsening of jaundice, and in severe cases may transition to acute on chronic liver failure when the risk for mortality, depending on the number of extra-hepatic organ failures, may be as high as 20-50% at 1 month. Corticosteroids provide short-term survival benefit in about half of treated patients with severe AH and long-term mortality is related to severity of underlying liver disease and is dependent on abstinence from alcohol. General measures in patients hospitalized with ALD include inpatient management of liver disease complications, management of alcohol withdrawal syndrome, surveillance for infections and early effective antibiotic therapy, nutritional supplementation, and treatment of the underlying alcohol-use disorder. Liver transplantation, a definitive treatment option in patients with advanced alcoholic cirrhosis, may also be considered in selected patients with AH cases, who do not respond to medical therapy. There is a clinical unmet need to develop more effective and safer therapies for patients with ALD.

Management of Delirium Tremens

Delirium tremens is recognized as a potentially fatal and debilitating complication of ethanol withdrawal. Research thus far has primarily focused on the prevention of delirium tremens.

Improving Nursing Knowledge of Alcohol Withdrawal: Second Generation Education Strategies

Christiana Care Health System implemented a Care Management Guideline for Alcohol Withdrawal Symptom Management, which provided direction for inpatient screening for alcohol withdrawal risk, assessment, and treatment. Nurses educated on its use expressed confusion with the use of the assessment tools, pharmacokinetics, and pathophysiology of alcohol withdrawal and delirium tremens. Reeducation was provided by nursing professional development specialists. Pre- and postsurveys revealed that nurses were more confident in caring for patients with alcohol withdrawal.

Acute alcohol toxicity and withdrawal in the emergency room and medical admissions unit

Alcohol-related hospital attendances and admissions continue to escalate despite a fall in alcohol consumption levels in the UK population overall. People with alcohol-related problems pose a significant and often disproportionate burden on acute medical services as their management is often complex and challenging. This article focuses on the management of alcohol intoxication, with particular emphasis on aggressive and possibly violent behaviour; alcohol withdrawal; fitting; and the prevention and treatment of Wernicke's encephalopathy.

From Antiquity to the N-Methyl-D-Aspartate Receptor: A History of Delirium Tremens

Delirium associated with excessive alcohol consumption has been known since antiquity. This condition became more common as the supply of distilled fermented liquors increased. Delirium, including delirium associated with excessive alcohol consumption, was for many centuries regarded as a form of brain inflammation - "phrenitis" - and was treated with depletion. At the end of the eighteenth century treatment by depletion of alcohol-related delirium began to be replaced by sedation and led to significantly better outcomes. Thomas Sutton established that alcohol-related delirium was a disease sui generis, distinct from phrenitis, and he named it delirium tremens. Because historical accounts of this disease are rare, brief, and not easily accessible, we offer this account of events that culminated in the discovery of the molecular basis of delirium tremens.

Acute withdrawal: diagnosis and treatment

Symptoms of alcohol withdrawal range in severity from mild "hangover" to fatal delirium tremens (DTs). Tremor, hallucinosis, and seizures usually occur within 48 hours of abstinence. Seizures tend to be generalized without focality, occurring singly or in a brief cluster, but status epilepticus is not unusual. DTs usually appears after 48 hours of abstinence and consists of marked inattentiveness, agitation, hallucinations, fluctuating level of alertness, marked tremulousness, and sympathetic overactivity. The mainstay of treatment for alcohol withdrawal is benzodiazepine pharmacotherapy, which can be used to control mild early symptoms, to prevent progression to DTs, or to treat DTs itself. Alternative less evidence-based pharmacotherapies include phenobarbital, anticonvulsants, baclofen, gamma-hydroxybutyric acid, beta-blockers, alpha-2-agonists, and N-methyl-d-aspartate receptor blockers. Treatment of DTs is a medical emergency requiring heavy sedation in an intensive care unit, with close attention to autonomic instability, fever, fluid loss, and electrolyte imbalance. Frequent comorbid disorders include hypoglycemia, liver failure, pancreatitis, sepsis, meningitis, intracranial hemorrhage, and Wernicke-Korsakoff syndrome.

Outpatient management of alcohol withdrawal syndrome

Approximately 2% to 9% of patients seen in a family physician's office have alcohol dependence. These patients are at risk of developing alcohol withdrawal syndrome if they abruptly abstain from alcohol use. Alcohol withdrawal syndrome begins six to 24 hours after the last intake of alcohol, and the signs and symptoms include tremors, agitation, nausea, sweating, vomiting, hallucinations, insomnia, tachycardia, hypertension, delirium, and seizures. Treatment aims to minimize symptoms, prevent complications, and facilitate continued abstinence from alcohol. Patients with mild or moderate alcohol withdrawal syndrome can be treated as outpatients, which minimizes expense and allows for less interruption of work and family life. Patients with severe symptoms or who are at high risk of complications should receive inpatient treatment. In addition to supportive therapy, benzodiazepines, either in a fixed-dose or symptom-triggered schedule, are recommended. Medication should be given at the onset of symptoms and continued until symptoms subside. Other medications, including carbamazepine, oxcarbazepine, valproic acid, and gabapentin, have less abuse potential but do not prevent seizures. Typically, physicians should see these patients daily until symptoms subside. Although effective treatment is an initial step in recovery, long-term success depends on facilitating the patient's entry into ongoing treatment.

[Management of alcohol withdrawal syndromes]

Paper presents proposal of guidelines concerning management of alcohol withdrawal syndromes. The paper is based on scientific medical societies standards, meta analyses and significant papers supporting some controversial questions. There are represented some practices used in intensive care units, that are not present in standards.

Problem based review: alcohol-use disorders on the Acute Medical Unit

Alcohol-use disorders including acute intoxication and withdrawal are common in the acute medical setting. Acute physicians should be aware of the indications for inpatient detoxification, and be able to liase with specialist alcohol services in the hospital and in the community to determine those patients for whom community-based detoxification may be beneficial. Additionally, it is important to recognise the benefit of Brief Interventions for higher-risk drinkers who are not yet dependent. For patients with confusion and a possible history of high alcohol intake and malnutrition, acute physicians should maintain a high index of suspicion for Wernicke's Encephalopathy and treat appropriately with parenteral thiamine.

Problem drinking--management in general practice

BACKGROUND

Management of problem drinking presents the general practitioner with similar challenges and rewards to those associated with the management of other chronic conditions.

OBJECTIVE

This article presents a framework for managing alcohol problems in general practice based on national guidelines for the treatment of alcohol problems.

DISCUSSION

General practitioners are well placed to undertake the management of drinking problems following an assessment of the amount of alcohol taken and the risks this poses for the individual and the people around them. This assessment starts the process of engagement and reflection on drinking habits and will inform the appropriate management approach. Brief interventions can result in reduction in drinking in nondependent drinkers. For dependent drinkers, treatment steps include assessing need for withdrawal management and developing a comprehensive management plan, which includes consideration of relapse prevention pharmacotherapy and psychosocial interventions. The patient's right to choose what they drink must be respected, and those who continue to drink in a problematic way can still be assisted, with compassion, within a harm reduction framework.

[Diagnostic and stating problems in delirium tremens cases]

THE AIM OF THE STUDY

To get to know the kinds and prevelence of diagnostic problems related to delirium tremens cases as well as their stating ramifications related to correctness of medical treatment.

MATERIAL AND METHODS

Twelve forensic psychiatric opinions of delirium tremens cases made in Adult Psychiatry Department of Medical University in Lodz in years 2002-2007 were assessed as far as correctness of medical treatment is concerned.

RESULTS AND CONCLUSIONS

In analyzed material of 12 delirium tremens patients no mistreatment cases were found. The most frequent reason of hospitalization was head trauma--7 cases (58%), among them 4 cases (33%) were the consequence of epileptic seizure. None of the patients was referred to psychiatric department and in most cases they were hospitalized in surgical wards--7 patients (58%) or neurological wards--4 patients (33%). During hospitalization in majority of patients--10 cases (83%) delirium tremens was observed on second day. 50% of patients were transferred to psychiatric wards. 11 (92%) of analised patients died. In all of the cases chronic alcoholism with delirium tremens accompanying as the one however indirect cause of death was revealed. The direct cause of death in all the cases was acute circulatory or circulatory and respiratory failure.

Is your medical/surgical patient withdrawing from alcohol?

Look beyond the stereotype. Any hospitalized patient could be dependent on alcohol-and at risk for alcohol withdrawal syndrome.

Managing acute behavioural problems in medicine

This conference outlined the concepts of managing behavioural disturbances in general hospital settings, and highlighted the importance of pre-emptive work, recognition and prevention of aggression; it also discussed the value of non-pharmacologic intervention and advocated for better communication between agencies and improving staff training. Only in this context can safety of patients and staff in hospitals be ensured.

Alcohol withdrawal syndrome: how to predict, prevent, diagnose and treat it

(1) When people who are physically dependent on alcohol stop drinking, they experience an alcohol withdrawal syndrome. The symptoms generally resolve spontaneously within a week, but more severe forms may be associated with generalised seizures, hallucinations and delirium tremens, which can be fatal. (2) We carried out a literature review in order to obtain answers to the following questions: how to predict or rapidly diagnose a severe alcohol withdrawal syndrome; how to prevent and treat this syndrome; how to manage severe forms; and how to deal with the risk of vitamin B1 deficiency. (3) The main risk factors for severe withdrawal syndrome are: chronic heavy drinking; a history of generalised seizures; and a history of delirium tremens. (4) Anxiety, agitation, tremor, excessive sweating, altered consciousness and hallucinations are signs of a severe withdrawal syndrome. (5) Individual support and effective communication seem to reduce the risk of severe withdrawal syndrome. (6) Oral benzodiazepines are the best-assessed drugs for preventing a severe alcohol withdrawal syndrome, particularly the risk of seizures. When given for a maximum of 7 days, the adverse effects are usually mild. (7) Clinical trials of other antiepileptics suggest they are less effective than benzodiazepines, and their addition to benzodiazepine therapy offers no tangible advantage. (8) Betablockers increase the risk of hallucinations, and clonidine increases the risk of nightmares, and the efficacy of these two drugs is not well documented. Neuroleptics increase the risk of seizures. There are no convincing data to support the use of magnesium sulphate or meprobamate (the latter carries a risk of serious adverse effects). Acamprosate, naltrexone and disulfiram are not beneficial in alcohol withdrawal. (9) Gradual withdrawal, i.e. ingestion of decreasing amounts of alcohol, has not been compared with other methods but is generally not recommended. (10) There are no specific recommendations on hydration. Note that excessive water-sodium intake carries a risk of pulmonary oedema in patients with heart disease. (11) As vitamin B1 deficiency is frequent and can lead to serious complications in alcohol-dependent patients, oral vitamin B1 supplementation is widely recommended, despite the absence of comparative trials. High doses must be used to compensate for poor absorption. Intravenous administration is best if patients have very poor nutritional status or severe complications such as Gayet-Wernicke encephalopathy (a medical emergency), even though rare anaphylactic reactions have been reported after vitamin B1 injection. (12) Planned alcohol withdrawal in specialised hospital units has been extensively studied. Outpatient withdrawal may be more appropriate for patients who are at low risk of developing severe withdrawal syndrome. (13) A large proportion of alcohol-dependent patients were excluded from trials of withdrawal strategies. These include elderly patients, patients with serious psychiatric or somatic disorders, and patients who are also dependent on other substances. (14) An oral benzodiazepine is the best-assessed treatment for a single episode of generalised seizures or hallucinations during alcohol withdrawal. (15) In randomised comparative trials benzodiazepines were more effective than neuroleptics in preventing delirium-related mortality. Currently, with appropriate fluid-electrolyte support, continuous monitoring of vital signs, and respiratory support if necessary, the mortality rate for delirium tremens is under 3%. (16) In practice, patients who are attempting to stop drinking alcohol need close personal support and communication, and a reassuring environment, as well as regular monitoring for early signs of a withdrawal syndrome; the latter may require benzodiazepine therapy.

Use of alcoholic beverages in VA medical centers

Background

Benzodiazepines are the first-line choice for the treatment of alcohol withdrawal syndrome. However, several hospitals continue to provide alcoholic beverages through their formulary for the treatment of alcohol withdrawal. While there are data on the prevalence of this practice in academic medical centers, there are no data on the availability of alcoholic beverages at the formularies of the hospitals operated by the department of Veteran's Affairs.

Methods

In this study, we surveyed the Pharmacy managers at 112 Veterans' Affairs Medical Centers (VAMCs) to ascertain the availability of alcohol on the VAMC formularies, and presence or lack of a policy on the use of alcoholic beverages in their VA Medical Center.

Results

Of the pharmacy directors contacted, 81 responded. 8 did not allow their use, while 20 allowed their use. There was a lack of a consistent policy across the VA medical centers on availability and use of alcoholic beverages for the treatment of alcohol withdrawal syndrome.

Conclusion

There is lack of uniform policy on the availability of alcoholic beverages across the VAMCs, which may create potential problems with difference in the standards of care.

A survey of delirium guidelines in Europe

OBJECTIVE

The aim of this study was to investigate the existence and content of delirium guidelines of the national psychiatric associations in Europe.

METHOD

A survey was sent by email to national coordinators of the European Association for Consultation-Liaison Psychiatry and Psychosomatics.

RESULTS

Responses were obtained for 12 of the 14 countries that were approached. Of these 12 countries, only two national psychiatric associations reported having national delirium guidelines. The Dutch Psychiatric Association was the only national psychiatric association that had developed a comprehensive multidisciplinary guideline on the diagnosis and treatment of delirium. The German Association of Scientific Medical Societies has a comprehensive guideline on the treatment of alcohol withdrawal delirium, in which the German Society for Psychiatry, Psychotherapy, and Mental Disorders participated. In addition, the delirium guideline of the British Geriatrics Society and the guideline for alcohol withdrawal delirium of the German Neurological Society were mentioned by respondents.

CONCLUSIONS

Although the development of evidence-based treatment guidelines is considered an important way to improve clinical practice, the national psychiatric associations of only two countries have such a guideline for the diagnosis and treatment of delirium. The advantages of supranational collaboration in the development of guidelines are stressed.

Experience with an adult alcohol withdrawal syndrome practice guideline in internal medicine patients

STUDY OBJECTIVE

To standardize treatment of alcohol withdrawal syndrome (AWS) in internal medicine patients using an adult AWS practice guideline with a symptom-triggered management approach.

DESIGN

Prospective interventional (pilot group) and retrospective (control group).

SETTING

University teaching hospital.

PATIENTS

Thirty-two internal medicine patients identified as being at risk for AWS and treated according to the AWS practice guideline who were compared with 49 internal medicine patients managed with nonstandardized approaches.

INTERVENTION

Patients in the pilot group were assessed using the AWS type indicator. They received lorazepam, clonidine, or haloperidol, based on AWS type indicator assessment and adult AWS practice guideline criteria.

MEASUREMENTS AND MAIN RESULTS

Data collected and analyzed were drugs administered to control AWS symptoms, use of sitters and physical restraints, length of hospital stay, and discharge from hospital receiving tapered drug therapy. Pilot patients received 46.6% less benzodiazepine (p=0.001), 20% more clonidine (p=0.01), and 18.2% more haloperidol (p=0.002) than control patients. No drug therapy was required in 19% of pilot patients compared with 2% of controls (p=0.01). Significantly more control (71.4%) than pilot patients (18.8%) were discharged with tapered benzodiazepine therapy (p

CONCLUSION

This pilot project suggests that internal medicine patients at risk for AWS can be managed with a standardized, symptom-triggered approach using decreased amounts of benzodiazepine in combination with adjunctive agents to treat adrenergic hyperactivity and delirium. Further data are necessary to determine the impact of the practice guideline on patient outcome measurements.

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Key Words Collapse

MESH Headings

• Adult
• Aged
• Female
• Humans
• Male
• Middle Aged
• Adrenergic alpha-Agonists/therapeutic use
• Alcohol Withdrawal Delirium/drug therapy
• Alcohol Withdrawal Delirium/psychology
• Alcohol Withdrawal Delirium/therapy
• Anti-Anxiety Agents/therapeutic use
• Antipsychotic Agents/therapeutic use
• Clonidine/therapeutic use
• Haloperidol/therapeutic use
• Hospitals, Teaching
• Internal Medicine
• Length of Stay
• Lorazepam/therapeutic use
• Pilot Projects
• Restraint, Physical
• Retrospective Studies
• Treatment Outcome
• Practice Guidelines as Topic

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Alcohol withdrawal as an underrated cause of agitated delirium and terminal restlessness in patients with advanced malignancy

A significant number of patients with terminal cancer experience terminal restlessness or an agitated delirium in the final days of life. Multifactorial etiologies may contribute to agitation and restlessness for any one patient; alcohol withdrawal may be underrated as a contributing factor. The symptoms and signs of alcohol withdrawal--autonomic dysfunction, tremor, anxiety, sleep disturbances, insomnia, and abnormal vital signs--may continue for 6 to 12 months after the cessation of alcohol. We report four patients with terminal restlessness in whom we believe alcohol withdrawal to be a significant causal factor and a fifth patient who subsequently benefited from our team's increased awareness of this clinical problem. Formal assessment of alcohol withdrawal may be of more value in the palliative setting than using the currently accepted assessment instruments. Many of the medications utilized for the treatment of agitated delirium and terminal restlessness in the palliative care setting are effective therapies for alcohol withdrawal.

The recognition and treatment of acute alcohol withdrawal

For most patients alcohol detoxification is a comparatively smooth process. However, on rare occasions life-threatening complications can occur. This article describes the symptoms of alcohol withdrawal that are likely to be encountered in a general hospital setting, and offers evidence-based guidance on monitoring the process and providing nursing care.

Alcohol: use, abuse and dependence

As a drug, alcohol has grave bio-psychosocial effects on patients, their families and society in general. It is very important that clinicians be able to recognise, admit and thoroughly treat alcoholism. Subsequent to the indicated treatment of intoxication and withdrawal, the clinician should outline sound incentives (external initially, becoming internal in time) for rehabilitation and continued sobriety. A variety of alcohol-induced medical and psychiatric disorders should be recognised by doctors, and should be treated or referred appropriately. The multidisciplinary team should be involved, and doctors should not hesitate to seek help and advice. Alcoholism is potentially quite treatable.

Alcohol withdrawal syndrome

The spectrum of alcohol withdrawal symptoms ranges from such minor symptoms as insomnia and tremulousness to severe complications such as withdrawal seizures and delirium tremens. Although the history and physical examination usually are sufficient to diagnose alcohol withdrawal syndrome, other conditions may present with similar symptoms. Most patients undergoing alcohol withdrawal can be treated safely and effectively as outpatients. Pharmacologic treatment involves the use of medications that are cross-tolerant with alcohol. Benzodiazepines, the agents of choice, may be administered on a fixed or symptom-triggered schedule. Carbamazepine is an appropriate alternative to a benzodiazepine in the outpatient treatment of patients with mild to moderate alcohol withdrawal symptoms. Medications such as haloperidol, beta blockers, clonidine, and phenytoin may be used as adjuncts to a benzodiazepine in the treatment of complications of withdrawal. Treatment of alcohol withdrawal should be followed by treatment for alcohol dependence.

[Psychiatric emergency cases in Hamm/Westfalen]

PURPOSE

Our study examines the frequency and further characteristics of psychiatric emergencies in the ambulance service of doctors on call in the city of Hamm.

METHODS/PATIENTS

All emergency documentations of the year 2000 were retrospectively examined and evaluated with regard to psychiatric disorders according to the ICD-10. In Hamm (181, 197 inhabitants) there were 3812 emergency calls for doctors on call in the examined period.

RESULTS

Due to internal emergencies, psychiatric diseases were diagnosed twice as often. Alcoholic intoxications (32.8 %), suicide attempts (16.8 %) and alcoholic withdrawal-syndromes were mostly diagnosed in psychiatric emergencies. Most patients were male. The average age was 41.7 years.

CONCLUSIONS

In the education for doctors on call, the training in the subject psychiatry is very low. Therefore the education and training of the diagnostic and therapy of psychiatric disorders must be intensified in the acquiring of the certification for ambulance service. acquiring

[The new poor expatriates in the third world]

This report describes four cases involving French expatriates who developed serious health problems while living destitute in Senegal. A 37-year-old man presented with embolism-like symptoms in relation with lung involvement due to spreading of untreated staphylococcal skin infection. A 64-year-old man was admitted for high output cardiac failure secondary to severe anemia caused by malnutrition. A 50-year-old man presented recurrent fever with loss of consciousness after successful treatment of neuromalaria and finally attributed to delirium tremens. A 25-year-old man was hospitalized with presumed meningoencephalitis that had been ongoing for two weeks. All four patients had been in Senegal for several months and had cut all ties to mainland France. Being jobless and homeless, they had been unable to obtain proper nutrition or medications. With minimal entry requirements and low-cost air travel, Senegal has been come a common sight-seeing destination and has developed a small but apparently growing population of destitute travelers. Alienation from the home community and resulting seclusion enhance clinical consequences and delay intervention by foreign service officials.

The alcohol hangover

PURPOSE

To review the cause, pathophysiologic characteristics, cost, and treatment of alcohol-induced hangover.

DATA SOURCES

A MEDLINE search of English-language reports (1966 to 1999) and a manual search of bibliographies of relevant papers.

STUDY SELECTION

Related experimental, clinical, and basic research studies.

DATA EXTRACTION

Data in relevant articles were reviewed, and relevant clinical information was extracted.

DATA SYNTHESIS

The alcohol hangover is characterized by headache, tremulousness, nausea, diarrhea, and fatigue combined with decreased occupational, cognitive, or visual-spatial skill performance. In the United States, related absenteeism and poor job performance cost $148 billion annually (average annual cost per working adult, $2000). Although hangover is associated with alcoholism, most of its cost is incurred by the light-to-moderate drinker. Patients with hangover may pose substantial risk to themselves and others despite having a normal blood alcohol level. Hangover may also be an independent risk factor for cardiac death. Symptoms of hangover seem to be caused by dehydration, hormonal alterations, dysregulated cytokine pathways, and toxic effects of alcohol. Physiologic characteristics include increased cardiac work with normal peripheral resistance, diffuse slowing on electroencephalography, and increased levels of antidiuretic hormone. Effective interventions include rehydration, prostaglandin inhibitors, and vitamin B6. Screening for hangover severity and frequency may help early detection of alcohol dependency and substantially improve quality of life. Recommended interventions include discussion of potential therapies and reminders of the possibility for cognitive and visual-spatial impairment. No evidence suggests that alleviation of hangover symptoms leads to further alcohol consumption, and the discomfort caused by such symptoms may do so. Therefore, treatment seems warranted.

CONCLUSIONS

Hangover, a common disorder, has substantial morbidity and societal cost. Appropriate management may relieve symptoms in many patients.

Identifying patients "at risk" for alcohol withdrawal syndrome and a treatment protocol

Alcohol abuse and alcohol dependence are common problems. It is estimated that more than 10 million Americans have problems with alcohol dependence that adversely affect their lives and the lives of their families. Many of these patients, if hospitalized, have the potential to experience symptoms of alcohol withdrawal. Major alcohol withdrawal symptoms may include seizures and the development of delirium tremens. Obtaining an alcohol consumption history is a critical component to identifying patients at risk and determining the appropriate treatment plan for potential alcohol withdrawal. A protocol was established for identifying and treating patients at risk for alcohol withdrawal. The initiation of the treatment protocol is history- and symptom-based; treatment is symptom-triggered on the basis of frequent objective assessments. The purpose of the protocol is to prevent and control withdrawal symptoms without heavily sedating or hindering a patients' neurological assessment.

Withdrawal syndromes

The pathophysiology of substance withdrawal is elucidated by a review of classic and cutting-edge research. The manifestation and evaluation of the associated withdrawal syndromes from ethanol, sedative-hypnotics, opioids, and baclofen, are compared. The general management of and pharmacotherapy for these patients are discussed.

Management of alcohol withdrawal in microvascular head and neck reconstruction

Alcohol use is a risk factor for head and neck cancer. One of the primary therapeutic modalities is surgical tumor ablation followed by immediate reconstruction. Such therapy places patients in a controlled environment, without alcohol, creating the risk of alcohol withdrawal syndrome. The authors attempted to identify the incidence of alcohol withdrawal among patients undergoing free-flap reconstruction for head and neck cancer and were interested in the effect of alcohol withdrawal on the postoperative course of affected patients. In this retrospective review of 51 patients, six experienced alcohol withdrawal or delirium tremens. No difference in the rate of overall complications was seen between the patients who experienced withdrawal and those who did not, although patients who experienced withdrawal did have a statistically significant ratio of non-flap-related to flap-related complications. A review of the current management for alcohol withdrawal is included and places an emphasis on preoperative screening, close observation, rapid diagnosis, and immediate medical care.

Life-threatening brain failure and agitation in the intensive care unit

The modern intensive care unit (ICU) has evolved into an area where mortality and morbidity can be reduced by identification of unexpected hemodynamic and ventilatory decompensations before long-term problems result. Because intensive care physicians are caring for an increasingly heterogeneous population of patients, the indications for aggressive monitoring and close titration of care have expanded. Agitated patients are proving difficult to deal with in nonmonitored environments because of the unpredictable consequences of the agitated state on organ systems. The severe agitation state that is associated with ethanol withdrawal and delirium tremens (DT) is examined as a model for evaluating the efficacy of the ICU environment to ensure consistent stabilization of potentially life-threatening agitation and delirium.

[Alcoholic delirium: warning signs and diagnosis]

Lately an increasing number of physicians are asked to diagnose and treat physical and mental disorders caused by alcohol abuse, a phenomena which had been quite rare in Israel until recently. Early diagnosis and efficient treatment are essential for the management of alcohol-dependent patients. Primary care physicians and hospital personnel should be more alert to the growing numbers of alcohol abusers and to their appropriate diagnosis and treatment. This article describes and summarizes the symptoms of alcohol withdrawal in general, and alcoholic delirium in particular. Problems in diagnosis and treatment are illustrated by typical cases, pointing out early clinical warning signs and suggesting some treatment guidelines.

[Use of sodium hypochlorite in the multimodal treatment of alcoholic delirium as a complication of acute poisoning]

Use of sodium hypochlorite in combined therapy of patients with alcoholic delirium complicating acute poisoning with psychotropic drugs, caustic poisons, alcohol and its surrogates resulted in an appreciable decrease in the duration of alcoholic delirium.

Delirium tremens

BACKGROUND

The hyperadrenergic syndrome, delirium tremens, as contrasted with tile milder alcohol withdrawal syndromes, is a medical emergency. The clinical features of delirium tremens were carefully described almost 200 years ago. Since then, many therapies have been suggested as superior to preceding therapeutic approaches. Unfortunately, morbidity and mortality remain relatively unchanged for the last 100 years.

METHODS

Using a literature review, we review the history of delirium tremens, including the suggested therapeutic approaches.

RESULTS/CONCLUSIONS

We recommend a rational approach to management and therapy, based on present knowledge.

[Delirium tremens in Israel]

We discuss pathogenetic aspects (biochemical, pharmacological) of delirium tremens (DT) in accordance with the acute clinical processes, the development of psychosis, and preventive treatment used in the various stages. A typical patient, a 33-year-old man, and the difficulties in diagnosis and treatment are presented and conclusions from the dangerous behavior of the patient are drawn.

Alcohol withdrawal syndrome: current management strategies for the surgery patient

PURPOSE

As advances in the therapeutic management of alcohol withdrawal syndrome occur, oral and maxillofacial surgeons should be aware of the current treatment philosophies and modalities. This article provides a comprehensive review of alcohol withdrawal syndrome and presents some of the current management strategies that can be used for these patients, whether it be in the office or in the hospital.