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

Alcohol Withdrawal Calculator

Nausea and Vomitting
No nausea or vomiting
Intermittent nausea with dry heaves
Constant nausea, frequent dry heaves and vomiting

Paroxysmal Sweats
No sweats visible
Barely perceptible sweat, palms moist
Beads of sweat obvious on forehead
Drenching sweats

Agitation
Normal activity
Somewhat more than normal activity
Moderate fidgety and restless
Paces back and forth during most of the interview or constantly thrashes about

Visual Disturbances
Not present
Very mild photosensitivity
Mild photosensitivity
Moderate photosensitivity
Moderately severe visual hallucinations
Severe visual hallucinations
Extreme severe visual hallucinations
Continuous visual hallucinations

Tremor
No tremor
Not visible, but can be felt at finger tips
Moderate when patient’s hands extended
Severe, even with arms not extended

Tactile Disturbances
Not present
Very mild paraesthesias
Mild paraesthesias
Moderate paraesthesias
Moderately severe paraesthesias
Severe paraesthesias
Extremely severe paraesthesias
Continuous paraesthesias

Headache
Not present
Very mild
Mild
Moderate
Moderately severe
Severe
Very severe
Extremely severe

Auditory Disturbances
Not present
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

Orientation and Clouding of the Sensorium
Oriented and can do serial additions
Cannot do serial additions
Disoriented for date but not more than 2 calendar days
Disoriented for date by more than 2 calendar days
Disoriented for place/person

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

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 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)

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

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.

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.