Laboratory findings Rarely, blood glucose is seriously depressed in the alcohol withdrawal states. Ketoacidosis with normal blood glucose is another infrequent finding. Disturbances of electrolytes are of varying frequency and significance. Serum sodium levels are altered infrequently and are more often increased than decreased. The same is true for chloride and phosphate. Serum calcium and potassium are lowered in about one-quarter of patients. Most patients show some degree of hypomagnesemia, low Pco2, and high arterial pH—abnormalities that are probably important in the pathogenesis of withdrawal symptoms (see later). Abnormalities of the CSF occur unpredictably (it is usually normal), as do changes on brain imaging studies; they may indicate the presence of some medical or surgical complication. Enlargement of the third and lateral ventricles is a common finding (see later). The MRI is normal unless there is an incipient Wernicke disease, in which case lesions in the periaqueductal region and hypothalamus may be evident, as described in the previous chapter.
Treatment of Delirium Tremens and Minor Withdrawal Symptoms (See Chap. 19)
The treatment of delirium tremens begins with a search for associated injuries (particularly head injury with cerebral lacerations or subdural hematoma), infections (pneumonia or meningitis), pancreatitis, and liver disease. Because of the frequency and seriousness of these complications, chest films and head imaging should be obtained in most instances, and lumbar puncture should be performed if there is suspicion of meningitis. In severe forms of delirium tremens, the temperature, pulse, and blood pressure should be measured at frequent intervals in anticipation of peripheral circulatory collapse and hyperthermia, which, added to the effects of injury and infection, are the usual causes of death in this disease. In the case of hypotension, one must act quickly, using intravenous fluids and, if called for, vasopressor drugs. The occurrence of hyperthermia demands the use of a cooling mattress or evaporative cooling in addition to specific treatment for any infection that may be present.
An additional important element in treatment is the correction of fluid and electrolyte imbalance, particularly hypokalemia and hypomagnesemia. Severe degrees of agitation and perspiration may require the administration of up to 5 L of fluid daily, of which at least 1,500 to 2,000 mL should be normal saline. The specific electrolytes and the amounts that must be administered are governed by the laboratory values for these electrolytes. If the serum sodium is extremely low, one must be cautious in raising the level lest a central pontine myelinolysis be induced (see Chap. 39). In the rare case of hypoglycemia, the administration of glucose is an urgent matter. Patients who present with severe alcoholic ketoacidosis and normal or only slightly elevated blood glucose concentrations usually recover promptly, without the use of insulin.
It must be emphasized, as it was in Chap. 40, that a special danger attends the use of glucose solutions in alcoholic patients. The administration of intravenous glucose may serve to consume the last available reserves of thiamine and precipitate Wernicke disease. Typically, these patients have subsisted on a diet disproportionately high in carbohydrate (in addition to alcohol, which is metabolized entirely as carbohydrate) and low in thiamine, and their body stores of B vitamins may have been further reduced by gastroenteritis and diarrhea. For this reason it is good practice to add B vitamins, specifically thiamine (which may also be supplemented by intramuscular injection), in all cases requiring parenterally administered glucose—even though the alcoholic disorder under treatment, for example, delirium tremens, is not primarily caused by vitamin deficiency.