From the Guidelines
A patient with mild alcohol withdrawal symptoms and a history of seizures should be discharged when they have been symptom-free for 24 hours, have stable vital signs, and show no signs of withdrawal progression, as recommended by the most recent guidelines 1. The Clinical Institute Withdrawal Assessment for Alcohol-Revised (CIWA-Ar) score should be consistently below 8-10 for at least 24 hours without requiring medication. Prior to discharge, ensure the patient has completed a benzodiazepine taper if one was initiated, typically using medications like lorazepam (1-2mg) or oxazepam, with gradually decreasing doses over 3-5 days, as these short-acting benzodiazepines are preferred in patients with liver disease 1. Given the patient's history of seizures, a slightly longer observation period may be warranted, and consideration should be given to prescribing a short course of anticonvulsant medication such as gabapentin (300-600mg three times daily) for 1-2 weeks post-discharge. The discharge plan should include:
- Arrangements for outpatient follow-up within 1-2 weeks
- Connection to addiction treatment services
- Clear instructions on medication management
- Prescription of thiamine to prevent Wernicke's encephalopathy, as recommended by recent guidelines 1 This cautious approach is necessary because patients with a history of withdrawal seizures have a higher risk of complications during subsequent withdrawal episodes, and the kindling phenomenon can make each withdrawal potentially more severe than previous ones. Key considerations in the management of alcohol withdrawal include:
- Regular monitoring to guide dosage adjustment and prevent seizures
- Personalized prescription that is symptom-adapted and favors short-acting drugs in patients with decompensated liver disease 1
- Avoidance of benzodiazepine accumulation in patients with hepatic insufficiency.
From the Research
Discharge Criteria for Patients with Mild Alcohol Withdrawal Symptoms and a History of Seizures
The decision to discharge a patient with mild alcohol withdrawal symptoms and a history of seizures should be based on careful evaluation and consideration of several factors.
- Patients with a history of seizures are at higher risk for severe withdrawal symptoms, including delirium tremens and further seizures 2.
- The Clinical Institute Withdrawal Assessment for Alcohol Scale, Revised (CIWA-Ar) is a commonly used tool to assess withdrawal symptoms, but its use is not essential for emergency medicine residents or faculty 3.
- Benzodiazepines are the first-line therapy for moderate to severe alcohol withdrawal symptoms, including seizures 4, 2, 5.
- Patients with mild to moderate withdrawal symptoms without additional risk factors for developing severe or complicated withdrawal can be treated as outpatients 5.
- Ambulatory withdrawal treatment should include supportive care and pharmacotherapy as appropriate, with daily monitoring for up to five days after the last drink to verify symptom improvement and evaluate the need for additional treatment 5.
Key Considerations for Discharge
Before discharging a patient with mild alcohol withdrawal symptoms and a history of seizures, the following considerations should be taken into account:
- The patient's symptoms should be well-controlled with medication, and they should be able to manage their symptoms at home 5.
- The patient should have a support system in place, such as a family member or friend, to monitor their condition and provide assistance if needed 2, 5.
- The patient should be aware of the risks of severe withdrawal symptoms, including seizures, and know how to seek medical attention if their symptoms worsen 2, 5.
- The patient should be scheduled for follow-up appointments to monitor their progress and adjust their treatment plan as needed 5.