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| | {| class="infobox" style="float:right;" |
| | | [[File:Siren.gif|30px|link= Alcohol withdrawal resident survival guide]]|| <br> || <br> |
| | | [[Alcohol withdrawal resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']] |
| | |} |
| __NOTOC__ | | __NOTOC__ |
| '''For patient information, click [[Alcohol withdrawal (patient information)|here]]''' | | {{Alcohol withdrawal}} |
| {{SI}}
| | '''For patient information click [[Alcohol withdrawal (patient information)|here]].''' |
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| {{CMG}} ; {{AE}} {{ADI}}
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| == Overview ==
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| Alcohol withdrawal refers to symptoms that may occur when a person who has been drinking too much [[alcohol]] every day '''suddenly stops''' drinking alcohol.
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| == Pathophysiology ==
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| * Prolonged exposure to alcohol results in inhibition of the inhibitory GABA A-type and NMDA-type glutamate receptors located in the CNS. Without the alcohol, greater CNS excitability results.
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| * Elevated [[norepinephrin]]e has been found in the [[CSF]] of withdrawing patients. It is postulated that alpha 2-receptors are decreased resulting in less inhibition of [[presynaptic]] [[norepinephrine]] release.
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| == Epidemiology and Demographics ==
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| * [[Alcohol abuse]] or dependence afflicts up to 15 million persons in the United States. It accounts for 100,000 deaths and an economic burden of over 100 billion dollars per year. The lifetime prevalence of alcohol abuse is approximately 14% and of alcohol dependence is 8%. Approximately 500,000 patients/year develop withdrawal that is severe enough to prompt pharmacologic management.
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| * Between 13% and 71% of persons admitted for detoxification have evidence of withdrawal.
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| * Approximately 3% of chronic alcoholics develop withdrawal seizures. Five percent of patients with alcohol withdrawal develop [[delirium tremens]] (DTs), which is associated with approximately 5% mortality.
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| == Natural history, Complications and Prognosis ==
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| How well a person does depends on the amount of organ damage and whether the person can stop drinking completely. Alcohol withdrawal may range from a mild and uncomfortable disorder to a serious, life-threatening condition. People who continue to drink a lot may develop health problems such as liver and heart disease. Most people who go through alcohol withdrawal make a full recovery. However, [[death]] is possible, especially if [[delirium tremens]] occurs.
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| == Diagnosis == | | {{CMG}}; {{AE}} {{SHA}}, {{ADI}} |
| | ==[[Alcohol withdrawal overview|Overview]]== |
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| === Criteria === | | ==[[Alcohol withdrawal historical perspective|Historical Perspective]]== |
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| # History of cessation or reduction in heavy and prolonged alcohol use.
| | ==[[Alcohol withdrawal classification|Classification]]== |
| # 2 or more of:
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| #:* Autonomic hypereactivity
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| #:* Hand [[tremor]]
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| #:* [[Insomnia]]
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| #:* [[Nausea ]]and [[vomiting]]
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| #:* Visual or auditory [[hallucinations]]
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| #:* Psychomotor agitation
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| #:* [[Anxiety]]
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| #:* [[Grand mal seizures]]
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| #:*:* Note history of [[blackouts]], morning shakes, prior detoxifications or [[DT]]s and frequency, amount and type of alcohol.
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| === Clinical Institute Withdrawal Assessment for Alcohol revised (CIWA-Ar) ===
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| The CIWA (Clinical Institute Withdrawal Assessment)<ref name="pmid16115538">{{cite journal |author=Puz CA, Stokes SJ |title=Alcohol withdrawal syndrome: assessment and treatment with the use of the Clinical Institute Withdrawal Assessment for Alcohol-revised |journal=Crit Care Nurs Clin North Am |volume=17 |issue=3 |pages=297–304 |year=2005 |month=September |pmid=16115538 |doi=10.1016/j.ccell.2005.04.001 |url=}}</ref> is a common measure used in North American hospitals to assess and treat alcohol withdrawal syndrome and for alcohol detoxification. This clinical tool assesses 10 common withdrawal signs.<ref name="pmid15029927">{{cite journal |author=McKay A, Koranda A, Axen D |title=Using a symptom-triggered approach to manage patients in acute alcohol withdrawal |journal=Medsurg Nurs |volume=13 |issue=1 |pages=15–20, 31; quiz 21 |year=2004 |month=February |pmid=15029927 |doi= |url=}}</ref> A score of more than '''15''' points is associated with increased risk of alcohol withdrawal effects such as [[confusion]] or [[seizures]].
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| [[Image:Alcoholwithdrawal.PNG|576 px|thumb|center|Alcohol withdrawal]] | |
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| ====Scoring====
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| {|
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| |-style="background:silver; color:black"
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| | '''Cumulative Score''' || '''Approach'''
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| |-style="background:silver; color:black"
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| | '''0-8''' || No medication needed
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| |- style="background:silver; color:black"
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| | '''9-14'''|| Medication is optional
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| |- style="background:silver; color:black"
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| | '''15-20'''|| Definitely needs medication
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| |- style="background:silver; color:black"
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| | '''>20'''|| Increased risk of [[Delirium tremens]]
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| |}
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| === Symptoms === | | ==[[Alcohol withdrawal pathophysiology|Pathophysiology]]== |
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| * '''Common symptoms include:'''
| | ==[[Alcohol withdrawal causes|Causes]]== |
| :* [[Anxiety]] or [[nervousness]]
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| :* [[Clinical depression|Depression]]
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| :* Not thinking clearly
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| :* [[Fatigue ]]
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| :* [[Irritability]]
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| :* Jumpiness or shakiness
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| :* Mood swings
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| :* [[Nightmares]]
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| * '''Other symptoms may include:'''
| | ==[[Alcohol withdrawal differential diagnosis|Differentiating Alcohol withdrawal from other Diseases]]== |
| :* [[Clammy skin]]
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| :* [[Enlarged (dilated) pupils]]
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| :* [[Headache ]]
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| :* [[Insomnia ]] ([[sleeping difficulty]])
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| :* [[Loss of appetite]]
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| :* [[Nausea]] and [[vomiting]]
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| :* [[Pallor]]
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| :* [[Rapid heart rate]]
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| :* [[Sweating]]
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| :* [[Tremor]] of the hands or other body parts
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| * A severe form of alcohol withdrawal called '''[[Delirium tremens ]]''' can cause:
| | ==[[Alcohol withdrawal epidemiology and demographics|Epidemiology and Demographics]]== |
| :* [[Agitation]]
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| :* [[Confusion ]]
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| :* Seeing or feeling things that aren't there ([[Hallucination]])
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| :* [[Fever]]
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| :* [[Seizures]]
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| === Physical examination === | | ==[[Alcohol withdrawal risk factors|Risk Factors]]== |
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| :* Abnormal eye movements
| | ==[[Alcohol withdrawal natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
| :* [[Abnormal heart rhythms]]
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| :* Not enough fluids in the body ([[dehydration]])
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| :* [[Rapid breathing]]
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| :* [[Rapid heart rate]]
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| :* [[Shaky hands]]
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| :* Blood and urine tests, including a [[toxicology screen]]
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| == Treatment == | | ==Diagnosis== |
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| * No clinical findings can reliably predict who will or will not develop withdrawal. Risk factors for [[DT]]s: Previous DTs or detoxifications, Age >30, high degree of alcohol dependence, duration of abuse, the presence of moderate symptoms (CIWA >14) left untreated and concurrent medical illness are all strongly predictive. These findings should prompt intervention. Time abstinent may be a helpful negative predictor. In one large study, patients who were asymptomatic 36 hours after their last drink did not develop symptoms.
| | [[Alcohol withdrawal diagnostic criteria|Diagnostic Criteria]] | [[Alcohol Withdrawal Calculator]] | [[Alcohol withdrawal history and symptoms| History and Symptoms]] | [[Alcohol withdrawal physical examination | Physical Examination]] | [[Alcohol withdrawal laboratory findings|Laboratory Findings]] | [[Alcohol withdrawal CT|CT]] | [[Alcohol withdrawal other imaging findings|Other Imaging Findings]] | [[Alcohol withdrawal other diagnostic studies|Other Diagnostic Studies]] |
| * All patients with [[alcohol abuse]] should receive 1mg [[folate]] QD, [[magnesium]]/ [[phosphate]]/[[potassium]]/fluid volume repletion and [[thiamine]] 100 mg IV/IM x1 then 100 mg QD.
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| * Treatment of alcohol related seizures is on an as needed basis with [[benzodiazepines]]. They tend to be transient phenomenon. [[phenytoin]] is ineffective in the management of withdrawal [[seizures]], but may be indicated if another seizure disorder or [[status epilepticus]] is present. Long term medical suppression or prophylaxis is not indicated for withdrawal seizures. [[Neuroleptics ]]lower the seizure threshold and should not be used in these patients; however, [[haloperidol]] has been used safely in conjunction with [[benzodiazepines]] (BDZs).
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| * BDZs are the cornerstone of therapy for minor withdrawal, [[seizures]] and DTs. Fixed schedule therapy, front loading therapy and symptom-triggered therapy have all been evaluated with similar efficacy. Symptoms triggered therapy was associated with less total administration of drug and shorter length of stay but has only been evaluated in patients without acute comorbid illness or [[seizures]] and should be restricted to only this limited group of patients.
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| * In the medically stable patient with no liver dysfunction 10 mg PO/IV is administered every hour till CIWA <10 or sedated. If the patient is stable but has [[liver disease]], give 2 mg [[lorazepam ]]IV/PO Q 1H till CIWA <10 or sedated. Calculate the total dose used and give this Q6H for 24 hrs. Use that latter regimen for the unstable patient.
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| * If CIWA is stable x24 hours then decrease the dose by 20%/day. If there is a history of [[DT]]s or [[seizures]] or the patient is unstable decrease the dose by 10%/day. Give parentral doses of [[lorazepam]] recurrence of withdrawal (CIWA >10).
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| ===Supportive Care=== | | ==Treatment== |
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| ===Inpatient v/s Outpatient===
| | [[Alcohol withdrawal medical therapy|Medical Therapy]] | [[Alcohol withdrawal surgery|Surgery]] | [[Alcohol withdrawal primary prevention|Primary Prevention]] | [[Alcohol withdrawal secondary prevention|Secondary Prevention]] | [[Alcohol withdrawal cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Alcohol withdrawal future or investigational therapies|Future or Investigational Therapies]] |
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| ===Nonpharmacological Treatment=== | | ==Case Studies== |
| ===Pharmacological Treatment===
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| ===Treatment of Complications===
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| ===Treatment in Special Groups===
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| ===Cost Effectiveness===
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| == References ==
| | [[Alcohol withdrawal case study one|Case#1]] |
| {{Reflist|2}}
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| {{WikiDoc Help Menu}}
| | ==Related Chapters== |
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| {{WS}}
| | * [[Mixing alcohol with medicines]] |
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| [[Category:Disease]] | | [[Category:Disease]] |
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| [[Category:Psychiatry]] | | [[Category:Psychiatry]] |
| [[Category:Toxicology]] | | [[Category:Toxicology]] |
| [[Category:Intensive Care Medicine]] | | [[Category:Intensive care medicine]] |
