Background
- Up to 30% of patients presenting to this ED with seizures will have alcohol-related seizure
- Withdrawal seizures are the leading cause of acute symptomatic seizures in adults
- Alcohol withdrawal seizures often occur 6 - 8 hours after cessation of alcohol use
- Seizures later than 24 hours after alcohol cessation are not alcohol-related but are usually due to a (treatable) structural lesion
- Seizures later than 24 hours after alcohol cessation are not alcohol-related but are usually due to a (treatable) structural lesion
- Chronic alcohol consumption causes adaptation and down-regulation of the GABA receptors (GABA-energic benzodiazepines are very effective in treatment) and up-regulation of the NMDA receptors (Ca++). Abrupt withdrawal causes hyperexcitability of NMDA neurons, sudden influx of calcium and results in withdrawal seizure
- Alcohol-related seizures are strongly dose-related - the risk of seizure is proportional to consumption
- "Kindling" i.e. repeated alcohol stimulation and withdrawal lowers the threshold for fitting, is believed to contribute to many alcohol related seizures
Evaluation
Similar approach to other causes of fitting. Patients may be unco-operative and difficult but try to get a relatively accurate history, most importantly why did they stop drinking. You must assume that a pathological ("treatable") process has prompted the patient to stop drinking.
Alcohol-related seizures are usually generalised, occurring without warning shortly after alcohol cessation. One quarter of such seizures may be of focal onset.
Assess for
- Hypoglycaemia, Infection, Structural Intracranial Lesion (classically SDH), Haemorrhagic stroke
- Hepatic failure, Peritonitis, GI bleed, Arrhythmia, Trauma, Include a neurological exam - focal signs, eye signs or meningism
- Lab studies include glucose, U&E, toxic screen, Ca++, Mg++, Septic screen including CXR, ? antiepileptic levels / alcohol levels ? LP
ALL alcoholics with a first fit should have an urgent CT head.
Management
- A B C (position, suction, oxygen)
- Don't Ever Forget Glucose
- Short duration seizures may not need immediate treatment
- Lorazepam (1 - 2mg IV) is used for the termination and prophylaxis of alcohol withdrawal seizures
- All patients should have a multivitamin infusion irrespective of disposal
- Anti-epileptics have no place in the treatment or prophylaxis of alcohol related seizures