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]
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)
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