ZSFG 7/7/2017: Altered mental status, Benzo withdrawal

Thank you to Albert Liu for presenting the case of a middle aged man with altered mental status, benzo use disorder, in which we discussed benzo withdrawal and rhabdo.

Top learning points

  1. Benzo withdrawal should be suspected in chronic benzo users who have abrupt reduction/cessation in benzo use; similarly to EtOH withdrawal, benzo withdrawal can be life threatening!
  2. AST comes from liver, heart, skeletal muscle, kidney and brain, whereas ALT is primarly from liver. AST elevation much greater than ALT should prompt you think of other sources of cell breakdown (including rhabdo!)
  3. Postictal confusion and somnolence may persist for several days to weeks in older patients, particularly if underlying neurocognitive disease.

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Benzo Withdrawal

  • Who: chronic users of benzodiazepines with abrupt cessation
  • When: the onset of withdrawal is dependent on the benzo involved, longer halflife benzo can have symptoms delayed up to weeks!
  • What: pts can have tremor, anxiety, seizure (similar to alcohol withdrawal!)
  • How: similar to EtOH, chronic benzodiazepine changes the activity of GABA receptors which ultimately results in decreased GABA activity, so sudden decrease of benzos allows less inhibition of excitatory transmitters = pro-excitatory state. This is manifested in tremor, tachycardia, etc.
  • Treatment: put these patients on CIWA and treat with a benzo with longer half life (eg diazepam)

 

Another mnemonic for altered mental status framework is MOVESTUPID, which can be helpful to think comprehensively through the whole differential.

  • Metabolic
  • Oxygen
  • Vascular (hypo/hypertension, CVA)
  • Endocrine
  • Seizure
  • Trauma/tumor/ttp
  • Uremia/hepatic encephalopathy
  • Psychiatric
  • Infections
  • Drugs
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