Alcohol withdrawal resident survival guide

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

Definition

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:

• Autonomic hyperactivity (e.g., sweating or heart rate > 100 beats/minute)
  
• Hand tremors
  
• Insomnia
  
• Nausea or vomiting
  
• Transient visual, tactile, or auditory hallucinations or illusions
  
• Psychomotor agitation
  
• Anxiety
  
• Grand mal seizures
  

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

Management

Shown below is an algorithm summarizing the approach to alcohol withdrawal.

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

Elicit 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 mg Diazepam 4 doses of 10 mg, then 8 doses of 5 mg Lorazepam 2 - 4 mg Lorazepam 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)

Do's

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

Dont's

• Do not use non-BZD's as a single therapy in the treatment of alcohol withdrawal but rather as adjunct treatment in case of failure of the treatment with BZD's.
• Do not use phenytoin to treat alcohol withdrawal seizures.