Health Dictionary
Reliable, easy-to-read patient information on common medical conditions — written in plain language, free of jargon, and grounded in current evidence. Browse the most frequent diagnoses, understand what they mean for everyday life, and learn which steps and questions help you have a focused conversation with your doctor.
Alcohol withdrawal resident survival guide
Introduction
Overview
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
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
- Autonomic hyperactivity (e.g., sweating or heart rate > 100 beats/minute)
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]
Management
Management
Shown below is an algorithm summarizing the approach to alcohol withdrawal.[2][3]
Template:Chart/cell^tTemplate:Chart/cell^bCharacterize the symptoms: Minor withdrawal symptoms: 6-12 hours ❑ Anorexia Alcoholic hallucinosis: 12-24 hours Withdrawal seizures: 24-48 hours Delirium tremens: 48-72 hours | |||||||||||||||||||||||||||||||||||||||||||||||||
Obtain a detailed history: ❑ Amount of alcohol intake per day Examine the patient: | |||||||||||||||||||||||||||||||||||||||||||||||||
Order labs: ❑ Complete blood count | |||||||||||||||||||||||||||||||||||||||||||||||||
Consider alternative diagnosis: ❑ Thyrotoxicosis | |||||||||||||||||||||||||||||||||||||||||||||||||
| 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:
❑ 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
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
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
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
References
- ↑ American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed., text revision. Washington, D.C.: American Psychiatric Association, 2000:216.
- ↑ Kosten, TR.; O’Connor, PG. (2003). “Management of drug and alcohol withdrawal”. N Engl J Med. 348 (18): 1786–95. doi:10.1056/NEJMra020617. PMID 12724485. Unknown parameter
|month=ignored (help) - ↑ 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) - ↑ 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) - ↑ 5.0 5.1 “WHO”. Retrieved 15 January 2014. Text ” Management of alcohol withdrawal ” ignored (help)
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Vidit Bhargava, M.B.B.S [2]