Alcohol withdrawal resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Vidit Bhargava, M.B.B.S [2]

Overview

Alcohol withdrawal is the array of signs and symptoms that occur within 6-48 hours following the abrupt cessation of alcohol intake in a chronic alcoholic.

Diagnostic Criteria

A. Sudden reduction or termination of chronic alcohol intake
B. The occurrence of two (or more) of the following within several hours to a few days following alcohol intake reduction or termination:

C. Clinically significant impairment of the patient's social, occupational or other aspects of life due to the symptoms in criterion B
D. Absence of a better explanation of the symptoms in criterion B by a general medical condition or other mental disorder[1]

Alcohol Withdrawal Calculator

Management

Shown below is an algorithm summarizing the approach to alcohol withdrawal.[2][3]

Characterize the symptoms:

Minor withdrawal symptoms: 6-12 hours

Anorexia
Anxiety/Palpitations
Diaphoresis
❑ Gastrointestinal upset
Headache
Insomnia


Alcoholic hallucinosis: 12-24 hours
❑ Visual hallucinations
❑ Auditory hallucinations
❑ Tactile hallucinations


Withdrawal seizures: 24-48 hours
Generalized tonic-clonic seizures


Delirium tremens: 48-72 hours
Hallucinations (predominately visual)
❑ Disorientation
Tachycardia
Hypertension
❑ Low-grade fever
❑ Agitation

Diaphoresis
Obtain a detailed history:

❑ Amount of alcohol intake per day
❑ Duration of alcohol use
❑ Time since last drink
❑ Previous alcohol withdrawals if any
❑ Presence of concurrent medical or psychiatric conditions
❑ Abuse of other substances


Examine the patient:
Arrhythmias
❑ Signs of congestive heart failure
❑ Signs of coronary artery disease
❑ Signs of gastrointestinal bleeding
❑ Signs of liver disease
❑ Nervous system impairment
❑ Signs of pancreatitis

Order labs:

Complete blood count
Liver function tests
❑ Urine drug screen
❑ Blood alcohol levels

Electrolytes levels
Consider alternative diagnosis:

Thyrotoxicosis
Anticholinergic drug poisoning
Amphetamine or cocaine abuse
❑ Withdrawal from other sedative-hypnotic agents

❑ Central nervous system infections/hemorrhage
Assess the severity of withdrawal based on CIWA-Ar scale
Mild withdrawal
Moderate to severe withdrawal or any one of the following:
❑ Past history of severe withdrawal symptoms
❑ History of withdrawal seizures or delirium tremens
❑ Multiple previous detoxifications
❑ Concomitant psychiatric or medical illness
❑ Recent high levels of alcohol consumption
❑ Pregnancy
❑ Lack of a reliable support network
Out-patient treatment
In-patient treatment
Provide general care:
❑ Fluid resuscitation
❑ Supplement thiamine (100 mg IV, before administering glucose) & multivitamins
❑ Correct electrolyte levels
❑ Improve nutrition
❑ Supplement magnesium sulfate if deficient
Provide general care:
❑ Fluid resuscitation
❑ Supplement thiamine (100 mg IV, before administering glucose) & multivitamins
❑ Correct electrolyte levels
❑ Improve nutrition
❑ Supplement magnesium sulfate if deficient

Administer drug therapy:

Symptom triggered regimen (Preferred)Fixed schedule regimen
Treat with one of the following every hour till CIWA-Ar falls below 8 Treat with one of the following every 6 hours till CIWA-Ar falls below 8
Chlordiazepoxide 50 - 100 mg or Chlordiazepoxide 4 doses of 50 mg, then 8 doses of 25 mg
Diazepam 10 - 20 mgDiazepam 4 doses of 10 mg, then 8 doses of 5 mg
Lorazepam 2 - 4 mgLorazepam 4 doses of 2 mg, then 8 doses of 1 mg

❑ In case of delirium tremens, higher doses of benzodiazepines (e.g. diazepam 10 mg IV repeated every 2-4 hours if seizure occurs)
❑ Monitor patient for at least 24 hours, by assessing CIWA-Ar scale every 4 to 8 hours
If not controlled consider adding an adjunct therapy with 1 or more of the following:
Phenothiazines
Haloperidol (reduces seizure threshold)
Beta blockers (esp in those with coronary disease)
Clonidine
Carbamazepine/phenytoin (seizure control only)


Assessment of Severity of Alcohol Withdrawal

  • The assessment of severity of alcohol withdrawal is based on "The revised Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar)" scale, which is a 10 item assessment tool used to monitor as well as to guide the treatment of patients undergoing alcohol withdrawal.
  • The interpretation of the CIWA-Ar scores is as follows:
  • ≤ 8 points: Mild withdrawal
  • 9 to 15 points: Moderate withdrawal
  • > 15 points: Severe withdrawal, associated with increased risk of delirium tremens and seizures[4]


Index of severity Score 0 Score 1 Score 2 Score 3 Score 4 Score 5 Score 6 Score 7
Nausea & vomiting None Mild nausea, no vomiting - - Intermittent nausea, dry heaves - - Constant nausea, frequent dry heaves, vomiting
Hand tremors None Tremor not visible but felt - - Moderate tremor with arms extended - - Severe tremors
Paroxysmal sweats None Barely perceptible, palms moist - - Beads of sweat on forehead - - Drenching sweats
Anxiety None Mild - - Moderate - - Equivalent to acute panic state
Agitation None Somewhat more than normal - - Moderately fidgety and restless - - Paces back and forth most of the time
Tactile disturbances
(Pins & needles)
(Bugs crawling under skin)
None Very mild itching, pins & needles, burning or numbness Mild itching, pins & needles, burning or numbness Moderate itching, pins & needles, burning or numbness Moderately severe hallucinations Severe hallucinations Extremely severe hallucinations Continuous hallucinations
Auditory disturbances None Very mild harshness or ability to frighten Mild harshness or ability to frighten Moderate harshness or ability to frighten Moderately severe hallucinations severe hallucinations Extremely severe hallucinations Continuous hallucinations
Visual disturbances None Very mild sensitivity Mild sensitivity Moderate sensitivity Moderately severe hallucinations severe hallucinations Extremely severe hallucinations Continuous hallucinations
Headache, fullness in head None Very mild Mild Moderate Moderately severe Severe Very severe Extremely severe
Orientation and clouding of sensorium Oriented, can do serial additions Cannot do serial additions/ uncertain about date Date disorientation by no more than 2 calendar days Date disorientation by more than 2 calendar days Disorientated for place and/or person - - -

Click here to assess the severity of alcohol withdrawal based on "The revised Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar)". scale.

Do's

  • Use benzodiazepines (BZD's) as the first choice drugs.
  • Always prefer longer acting BZD's as they have less abuse liability, unless the patient has a co-existing liver disease.
  • Treat patients with alcohol withdrawal for approximately 7 days unless delirium tremens is present.
  • Evaluate patients treated on an out-patient basis daily and explain to them when to return to the hospital in case of an exacerbation.
  • Supplement with thiamine before giving IV glucose to prevent the development of Wernicke's encephalopathy. If Wernicke's encephalopathy is suspected, administer IV thiamine twice daily for 5 days.[5]

Dont's

  • Do not use non-BZD's as a single therapy in the treatment of alcohol withdrawal but rather as an adjunct treatment in case of failure of the treatment with BZD's.
  • Do not use phenytoin to treat or prevent alcohol withdrawal seizures as BZD's are preferred.
  • Do not discharge patients at risk for repeated withdrawal, treat them as in-patients. These include patients with physical or psychiatric disorders or those who do not have a good social support.[5]

References

  1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed., text revision. Washington, D.C.: American Psychiatric Association, 2000:216.
  2. Kosten, TR.; O'Connor, PG. (2003). "Management of drug and alcohol withdrawal.". N Engl J Med. 348 (18): 1786–95. PMID 12724485. doi:10.1056/NEJMra020617.  Unknown parameter |month= ignored (help)
  3. Bayard, M.; McIntyre, J.; Hill, KR.; Woodside, J. (2004). "Alcohol withdrawal syndrome.". Am Fam Physician. 69 (6): 1443–50. PMID 15053409.  Unknown parameter |month= ignored (help)
  4. Sullivan, JT.; Sykora, K.; Schneiderman, J.; Naranjo, CA.; Sellers, EM. (1989). "Assessment of alcohol withdrawal: the revised clinical institute withdrawal assessment for alcohol scale (CIWA-Ar).". Br J Addict. 84 (11): 1353–7. PMID 2597811.  Unknown parameter |month= ignored (help)
  5. 5.0 5.1 "WHO". Retrieved 15 January 2014.  Text " Management of alcohol withdrawal " ignored (help)

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