- 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
- 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
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. See background). One quarter of such fits may be of focal onset.
- 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.
- A B C (position, suction, oxygen)
- Don't Ever Forget Glucose
- Short duration fits 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
- Conventional anti-epileptics have NO place in the treatment or prophylaxis of alcohol related seizures
- Prophylaxis of rum fits consists of chlordiazepoxide (librium)