View source for Alcohol withdrawal resident survival guide

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==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<br>
B. The occurrence of two (or more) of the following within several hours to a few days following alcohol intake reduction or termination:<br>
:* Autonomic hyperactivity (e.g., [[sweating]] or heart rate > 100 beats/minute)<br>
:* Hand [[tremors]]<br>
:* [[Insomnia]]<br>
:* Nausea or vomiting<br>
:* Transient visual, tactile, or auditory [[hallucinations]] or illusions<br>
:* Psychomotor agitation<br>
:* [[Anxiety]]<br>
:* [[Grand mal seizures]]<br>
C. Clinically significant impairment of the patient's social, occupational or other aspects of life due to the symptoms in criterion B <br>
D. Absence of a better explanation of the symptoms in criterion B by a general medical condition or other mental disorder<ref>American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed., text revision. Washington, D.C.: American Psychiatric Association, 2000:216.</ref>

==[[Alcohol Withdrawal Calculator]]==

==Management==
Shown below is an algorithm summarizing the approach to alcohol withdrawal.<ref name="Kosten-2003">{{Cite journal  | last1 = Kosten | first1 = TR. | last2 = O'Connor | first2 = PG. | title = Management of drug and alcohol withdrawal. | journal = N Engl J Med | volume = 348 | issue = 18 | pages = 1786-95 | month = May | year = 2003 | doi = 10.1056/NEJMra020617 | PMID = 12724485 }}</ref><ref name="Bayard-2004">{{Cite journal  | last1 = Bayard | first1 = M. | last2 = McIntyre | first2 = J. | last3 = Hill | first3 = KR. | last4 = Woodside | first4 = J. | title = Alcohol withdrawal syndrome. | journal = Am Fam Physician | volume = 69 | issue = 6 | pages = 1443-50 | month = Mar | year = 2004 | doi =  | PMID = 15053409 }}</ref>

{{chart/start |summary=PE diagnosis Algorithm.}}
{{chart | | | | | | | FOO | |FOO=<div style="text-align: left; line-height: 150% ">'''Characterize the symptoms:'''<br><br> '''Minor withdrawal symptoms: 6-12 hours'''<br>
❑ [[Anorexia]]<br>
❑ [[Anxiety]]/[[Palpitations]]<br>
❑ [[Diaphoresis]]<br>
❑ Gastrointestinal upset<br>
❑ [[Headache]]<br>
❑ [[Insomnia]]<br>
----
'''Alcoholic hallucinosis: 12-24 hours'''<br>
❑ Visual hallucinations<br>
❑ Auditory hallucinations<br>
❑ Tactile hallucinations
----
'''Withdrawal seizures: 24-48 hours'''<br>
❑ [[Generalized tonic-clonic seizures]]
----
'''Delirium tremens: 48-72 hours'''<br>
❑ [[Hallucination]]s (predominately visual)<br>
❑ Disorientation<br>
❑ [[Tachycardia]]<br>
❑ [[Hypertension]]<br>
❑ Low-grade [[fever]]<br>
❑ Agitation<Br>
❑ [[Diaphoresis]]</div>}} 
{{chart | | | | | | | |!| | | | | | | | | }}
{{chart | | | | | | | BAR | | | | | | | | |BAR=<div style="text-align: left; line-height: 150% ">'''Obtain a detailed history:'''<br>
❑ Amount of alcohol intake per day<br>
❑ Duration of alcohol use<br>
❑ Time since last drink<br>
❑ Previous alcohol withdrawals if any<Br>
❑ Presence of concurrent medical or psychiatric conditions<br>
❑ Abuse of other substances
----
'''Examine the patient:'''<br>
❑ [[Arrhythmias]]<br>
❑ Signs of [[congestive heart failure]]<br>
❑ Signs of [[coronary artery disease]]<br>
❑ Signs of [[gastrointestinal bleeding]]<br>
❑ Signs of [[liver disease]]<br>
❑ Nervous system impairment<br>
❑ Signs of [[pancreatitis]]
</div> }}
{{chart | | | | | | | |!| | | | | | | }}
{{chart | | | | | | | CZERO | | | | | | |CZERO=<div style="text-align: left; line-height: 150% ">'''Order labs:'''<br>
❑ [[CBC|Complete blood count]]<br>
❑ [[LFT|Liver function tests]]<br>
❑ Urine drug screen<br>
❑ Blood alcohol levels<br>
❑ [[Electrolyte]]s levels </div>}}
{{chart | | | | | | | |!| | | | | | | }}
{{chart | | | | | | | DZERO | | | | | | |DZERO=<div style="text-align: left; line-height: 150% ">'''Consider alternative diagnosis:'''<br>
❑ [[Thyrotoxicosis]]<br>
❑ [[Anticholinergic]] drug poisoning<br>
❑ [[Amphetamine]] or [[cocaine]] abuse<br>
❑ Withdrawal from other sedative-hypnotic agents<br>
❑ Central nervous system infections/hemorrhage </div>}}
{{chart | | | | | | | |!| | | | | | | | }}
{{chart | | | | | | | EZERO | | | | | | | | |EZERO= '''[[Alcohol withdrawal resident survival guide#Assessment of Severity of Alcohol Withdrawal|Assess the severity of withdrawal based on CIWA-Ar scale]]'''}}
{{chart | | | |,|-|-|-|^|-|-|-|.| | | | | }}
{{chart | | | FZO | | | | | | FZT | | | | |FZO='''Mild withdrawal''' |FZT=<div style="text-align: left; line-height: 150% ">'''Moderate to severe withdrawal or any one of the following:''' <br> ❑  Past history of severe withdrawal symptoms <br> ❑ History of withdrawal seizures or [[delirium tremens]] <br> ❑ Multiple previous detoxifications <br> ❑ Concomitant psychiatric or medical illness <br> ❑ Recent high levels of alcohol consumption <br> ❑ Pregnancy <br> ❑ Lack of a reliable support network </div> }}
{{chart | | | |!| | | | | | | |!| | | | | | | | | }}
{{chart | | | GZO | | | | | | GZT | | | | | | | |GZO= '''Out-patient treatment''' |GZT= '''In-patient treatment''' }}
{{chart | | | |!| | | | | | | |!| | | | | | | | | }}
{{chart | | | HZO | | | | | | HZT | | | | | | | |HZO=<div style="text-align: left; line-height: 150% "> '''Provide general care:''' <br> ❑ Fluid resuscitation <br> ❑ Supplement thiamine (100 mg IV, before administering glucose) & multivitamins<br> ❑ Correct electrolyte levels <br> ❑ Improve nutrition <br> ❑ Supplement magnesium sulfate if deficient </div> |HZT=<div style="text-align: left; line-height: 150% "> '''Provide general care:''' <br> ❑ Fluid resuscitation <br> ❑ Supplement thiamine (100 mg IV, before administering glucose) & multivitamins <br> ❑ Correct electrolyte levels <br> ❑ Improve nutrition <br> ❑ Supplement magnesium sulfate if deficient
----
❑ '''Administer drug therapy:'''<br>
<table class="wikitable">
<tr class="v-firstrow"><th>Symptom triggered regimen (Preferred)</th><th>Fixed schedule regimen</th></tr>
<tr><td>Treat with one of the following every hour till CIWA-Ar falls below 8</td><td> Treat with one of the following every 6 hours till CIWA-Ar falls below 8</td></tr>
<tr><td>[[Chlordiazepoxide]] 50 - 100 mg or</td><td> Chlordiazepoxide 4 doses of 50 mg, then 8 doses of 25 mg</td></tr>
<tr><td>[[Diazepam]] 10 - 20 mg</td><td>Diazepam 4 doses of 10 mg, then 8 doses of 5 mg</td></tr>
<tr><td>[[Lorazepam]] 2 - 4 mg</td><td>Lorazepam 4 doses of 2 mg, then 8 doses of 1 mg </td></tr>
</table> <br>
❑ In case of [[delirium tremens]], higher doses of [[benzodiazepines]] (e.g. diazepam 10 mg IV repeated every 2-4 hours if seizure occurs)</div>}}
{{chart | | | |!| | | | | | | |!| | | | | | | | | }}
{{chart | | | IZO | | | | | | IZT | | | | | | | | IZO= ❑ Monitor patient for at least 24 hours, by assessing CIWA-Ar scale every 4 to 8 hours| IZT= <div style="text-align: left; line-height: 150% ">'''If not controlled consider adding an adjunct therapy with 1 or more of the following:''' <br> ❑ [[Phenothiazines]] <br> ❑ [[Haloperidol]] (reduces seizure threshold) <br> ❑ [[Beta blockers]] (esp in those with coronary disease) <br> ❑ [[Clonidine]] <br> ❑ [[Carbamazepine]]/[[phenytoin]] (seizure control only)</div>}}
{{chart/end}}
<br>

==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<ref name="Sullivan-1989">{{Cite journal  | last1 = Sullivan | first1 = JT. | last2 = Sykora | first2 = K. | last3 = Schneiderman | first3 = J. | last4 = Naranjo | first4 = CA. | last5 = Sellers | first5 = EM. | title = Assessment of alcohol withdrawal: the revised clinical institute withdrawal assessment for alcohol scale (CIWA-Ar). | journal = Br J Addict | volume = 84 | issue = 11 | pages = 1353-7 | month = Nov | year = 1989 | doi =  | PMID = 2597811 }}</ref>


{| class="wikitable"

|-

! 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 <br> (Pins & needles) <br> (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 [[Alcohol withdrawal#Alcohol Withdrawal Calculator|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.<ref name="www.who.int">{{Cite web  | last =  | first =  | title = WHO | Management of alcohol withdrawal | url = http://www.who.int/mental_health/mhgap/evidence/alcohol/q2/en/ | publisher =  | date =  | accessdate = 15 January 2014 }}</ref>

==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.<ref name="www.who.int">{{Cite web  | last =  | first =  | title = WHO | Management of alcohol withdrawal | url = http://www.who.int/mental_health/mhgap/evidence/alcohol/q2/en/ | publisher =  | date =  | accessdate = 15 January 2014 }}</ref>

==References==
{{Reflist|2}}

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