Saturday, February 07, 2009

Shakin', Shakin', Shakes

The shakes. The shivers. The heebie jeebies. The jitterbugs. The jimjams. The horrors. The screaming meemies. The blue devils. Snakes in the boot. The DTs. All are expressions that refer to a clinical phenomenon known as delerium tremens ---- delerium associated with alcohol (or benzodiazepine) withdrawal. Why, pray tell, does a surgeon care about alcohol withdrawal? Because I see it, and not infrequently.

I like a good martini now and then. I've even enjoyed a glass of Delerium Tremens beer recently (oh, it was good). But I am not in the category of an Olympic caliber drinker, one who consumes a fair amount of alcohol on a daily basis. The dedicated drinker is the kind of patient who causes all kinds of havoc for us, and not just in the realm of trauma.

Alcohol can be a wonderful thing. A social lubricant, a relaxing tonic, a stress reliever, an enjoyable companion with a good meal, and in some forms possibly a good thing for your heart. It can also be destructive, a massive earthquake that destroys lives and tears apart families. I'll leave the social issues about alcoholism aside for this post, but I'd like to let you in on a little secret --- alcohol withdrawal is not a glamorous downward spiral or a simple hangover. It is an ugly, depressing, and potential deadly process. Unfortunately, we often see this when we least expect it.

Not surprisingly, many folks are a tad less than honest with their physicians. Alcohol dependence isn't as readily detected as, say, hypertension, a heart murmur, gallstones or appendicitis. We don't have a screening test available, and we thus must rely on a patient to be as forthright as possible when we ask the question "how much do you drink?" For obvious reasons, most answer with a miniscule fraction of what their real booze allotment really is --- I trained in Salt Lake City, where this question was frequently seen as an insult, but alcoholism knows no religious boundaries and I was given false information just as frequently there as here in Colorado.

For surgeons, especially those who work on the GI tract, an alcoholic can pose a vexing challenge. Basically, when a patient that overindulges regularly is hospitalized, the pint of vodka he usually downs on a daily basis is not readily available. For short hospitalizations of a day or so, this will generate irritability, nervousness, and shakiness ---- all relieved with a stop at the package store on the way home. For longer hospitalizations, it gets progressively worse, with nausea, headache, insomnia, excessive sweating, tachycardia, tremors and a variety of involuntary movements (such as constant picking at clothes, skin, and sheets) joining the display. This is the point where we generally pick up on the diagnosis --- basically the patient has the shakes.

A fault runs through the valley
It's long as it is mean
It starts to tear into the earth
And gets all in between
It shakes up through the mountains
It shakes down to the sea
It shakes up to the volcano
And then it starts to scream
And then it starts to shine
And Lord, it makes me tremble
And Lord, it makes me tremble
It's shakin' and shakin' and shakes

By this time, without a quick infusion of a couple of stiff drinks, the patient is well on his way to full blown withdrawal, marked by profound agitation, hallucinations, fever, convulsions, severe autonomic nervous system overactivity, and possibly death --> delerium tremens. We treat this by making a bargain with the patient's body --- if we give enough sedation, generally in the form of Ativan or another benzodiazepine, hopefully we can stave off the severe physiologic effects of alcohol withdrawal until the process passes. The tradeoff is that the patient must be pretty snockered, meaning ICU care, careful monitoring, a need for restraints, nutritional support, and a risk for aspiration. More severe cases may involve mechanical ventilation, particularly in the patient who has undergone major surgery or suffered severe trauma. Beta blockers and Clonidine also help mitigate the systemic effects of alcohol withdrawal, and though it seems a little bizarre, IV ethanol infusion has been used as an alternative to benzos.

Needless to say, it is often the case that alcohol withdrawal is often far worse than the other underlying reason a patient is hospitalized. It is also a big expense, one that is rarely reimbursed.

And Lord, it makes me tremble
And Lord, it makes me tremble
She's shakin' and shakin' and shakes