Case history

Case history

A 45-year-old man presents to the emergency department with restlessness and tremors. He is anxious, pacing in the hallway. Initial vital signs show a heart rate of 121 beats per minute and blood pressure of 169/104 mmHg; other vital signs are normal. On further questioning by the nurse he states that he is nauseous and wants something to help with the shakes. During physician interview, the patient admits to heavy alcohol use and that he is trying to cut down on drinking. He also says that his current symptoms started to develop about 6 hours after his last drink.

Other presentations

Common symptoms of alcohol withdrawal include anxiety, restlessness, nausea or vomiting, autonomic dysfunction, and insomnia.[3][6][7][8]

Mild to moderate withdrawal may start as early as 6-24 hours after the last drink, and peaks at 24-36 hours.[1][2][3][6][9] Alcohol withdrawal delirium is a life-threatening feature of severe alcohol withdrawal, which generally occurs 48-72 hours after the last alcoholic drink, and peaks at 5 days.[1][5][6] Alcohol withdrawal delirium is characterized by confusion, delirium (which can include hallucinations and delusions), coarse tremor, and features of hemodynamic instability.[10][11][12] Alcohol withdrawal hallucinations usually appear within 12-24 hours of cessation of, or reduction in, alcohol intake.[5][6] Alcohol withdrawal hallucinations do not always progress to alcohol withdrawal delirium, and usually resolve within 24-48 hours if no other signs and symptoms of alcohol withdrawal delirium develop.[5] Alcohol withdrawal seizures typically occur in the first 12-24 hours after the patient's last alcoholic drink.[12] Alcohol withdrawal seizures can appear as early as 8 hours after cessation of, or reduction in, alcohol use; peak seizure activity is typically seen after 24 hours.[5] Signs of an imminent seizure can include tremor, hypertension, tachycardia, fever, and hyperreflexia, though alcohol withdrawal seizures may occur in the absence of other clinical signs and symptoms of acute withdrawal.[5]

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