What are the key differences in signs and management between Ethanol (ETOH) intoxication and withdrawal?

Key Differences Between Ethanol Intoxication and Withdrawal

The primary distinction between ethanol intoxication and withdrawal is that intoxication presents with CNS depression symptoms while withdrawal manifests as CNS hyperexcitability, with different management approaches required for each condition.

Clinical Presentation Comparison

Ethanol Intoxication

• Timing: Occurs during or shortly after alcohol consumption
• CNS Effects: Depression of central nervous system
• Vital Signs:
  • Hypotension
  • Bradycardia (in severe cases)
  • Hypothermia
  • Respiratory depression (in severe cases)
• Neurological Signs:
  • Slurred speech
  • Ataxia and incoordination
  • Impaired cognition
  • Sedation progressing to stupor/coma at high levels
• Behavioral Signs:
  • Disinhibition
  • Emotional lability
  • Poor judgment
• Severity Indicators: Blood alcohol concentration (BAC)
  • Mild impairment: 50-100 mg%
  • Moderate impairment: 100-250 mg%
  • Severe impairment/coma risk: >250 mg% 1

Ethanol Withdrawal

• Timing: Occurs 6-24 hours after cessation of alcohol in habitual drinkers
• CNS Effects: Hyperexcitability of central nervous system
• Vital Signs:
  • Hypertension
  • Tachycardia
  • Hyperthermia
  • Tachypnea
• Neurological Signs:
  • Tremor (particularly hand tremor)
  • Hyperreflexia
  • Seizures (typically 12-48 hours after cessation)
  • Altered mental status progressing to delirium tremens in severe cases
• Behavioral Signs:
  • Anxiety
  • Agitation
  • Hallucinations (visual, tactile)
  • Disorientation
• Severity Indicators: Clinical Institute Withdrawal Assessment for Alcohol (CIWA) score 2

Pathophysiology

Intoxication

• Ethanol enhances inhibitory GABA neurotransmission and inhibits excitatory glutamate neurotransmission
• Affects cell membrane fluidity and function of membrane-associated proteins 1
• Results in overall CNS depression

Withdrawal

• Compensatory upregulation of glutamate receptors and downregulation of GABA receptors during chronic alcohol use
• When alcohol is removed, the balance shifts toward CNS hyperexcitability
• Increased noradrenergic activity contributes to autonomic symptoms
• Multiple withdrawal episodes can potentiate severity of subsequent withdrawals through a "kindling" mechanism 3, 4

Management Approaches

Ethanol Intoxication

1. Supportive Care:

   • Airway protection
   • IV fluids for dehydration
   • Monitoring vital signs
   • Positioning to prevent aspiration

2. Nutritional Support:

   • Thiamine (vitamin B1) administration before glucose to prevent Wernicke's encephalopathy
   • Glucose administration if hypoglycemic 1

3. Observation:

   • Monitor until BAC decreases to non-toxic level
   • Ethanol metabolizes at approximately 15 mg%/hour in non-dependent adults 1

4. Special Considerations:

   • Psychiatric evaluation should be based on cognitive abilities rather than specific BAC 2
   • Consider period of observation to determine if psychiatric symptoms resolve as intoxication resolves 2

Ethanol Withdrawal

1. Assessment:

   • Use standardized scoring system (CIWA) to assess severity 2
   • Monitor for signs of autonomic hyperactivity, cognitive deficits, seizures

2. Pharmacological Management:

   • Benzodiazepines are first-line treatment:
     • Long-acting benzodiazepines (chlordiazepoxide, diazepam) preferred for seizure prevention
     • Lorazepam recommended for patients with liver failure, respiratory issues, or serious medical comorbidities
     • Initial dosage of lorazepam 6-12 mg/day, tapered after resolution of symptoms 2

3. Nutritional Support:

   • Thiamine supplementation (100-300 mg/day) for all patients with AWS
   • Continue for 2-3 months after resolution of withdrawal symptoms 2

4. Monitoring and Disposition:

   • Inpatient treatment recommended for cases with serious complications (delirium, seizures)
   • Psychiatric consultation recommended for evaluation, treatment, and long-term planning 2

Clinical Pitfalls and Caveats

1. Diagnostic Challenges:

   • High CIWA scores may be seen in conditions similar to AWS such as anxiolytic withdrawal, anxiety disorder, sepsis, hepatic encephalopathy, and severe pain 2
   • Alcohol withdrawal seizures should be distinguished from other seizure disorders

2. Management Considerations:

   • Alcohol withdrawal seizures are a rebound phenomenon and typically don't require anticonvulsants 2
   • Delirium tremens is a medical emergency with significant mortality risk if untreated
   • Symptoms of withdrawal typically peak at 3-5 days after cessation 2

3. Special Populations:

   • Patients with history of multiple withdrawal episodes may experience more severe symptoms due to kindling phenomenon 3, 4
   • Patients with comorbid medical conditions require closer monitoring

4. Disposition Decisions:

   • Psychiatric facilities typically will not accept transfers of inebriated patients 2
   • Cognitive function should be assessed individually rather than relying solely on BAC when determining readiness for psychiatric evaluation 2

By understanding these key differences, clinicians can more effectively diagnose and manage patients with ethanol-related presentations, ultimately improving outcomes and reducing morbidity and mortality.