Alcohol withdrawal resident survival guide: Difference between revisions
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==Management== | ==Management== | ||
Shown below is an algorithm summarizing the approach to | Shown below is an algorithm summarizing the approach to alcohol withdrawal. | ||
{{familytree/start |summary=PE diagnosis Algorithm.}} | {{familytree/start |summary=PE diagnosis Algorithm.}} | ||
{{familytree | | | | | | | A01 | |A01=<div style="float: left; text-align: left; line-height: 150% ">'''Characterize the symptoms:'''<br> Minor withdrawal symptoms: 6-12 hours | {{familytree | | | | | | | A01 | |A01=<div style="float: left; text-align: left; line-height: 150% ">'''Characterize the symptoms:'''<br> Minor withdrawal symptoms: 6-12 hours<br> | ||
<div class="mw-collapsible-content"> | <div class="mw-collapsible-content"> | ||
<div class="mw-collapsible mw-collapsed"> | <div class="mw-collapsible mw-collapsed"> | ||
❑ Anorexia | ❑ Anorexia<br> | ||
❑ Anxiety/Palpitations | ❑ Anxiety/Palpitations<br> | ||
❑ Diaphoresis | ❑ Diaphoresis<br> | ||
❑ Gastrointestinal upset | ❑ Gastrointestinal upset<br> | ||
❑ Headache | ❑ Headache<br> | ||
❑ Insomnia | ❑ Insomnia<br> | ||
❑ Tremulousness </div></div> | ❑ Tremulousness </div></div> | ||
---- | ---- | ||
Alcoholic hallucinosis: 12-24 hours | Alcoholic hallucinosis: 12-24 hours<br> | ||
<div class="mw-collapsible-content"> | <div class="mw-collapsible-content"> | ||
<div class="mw-collapsible mw-collapsed"> | <div class="mw-collapsible mw-collapsed"> | ||
❑ Visual hallucinations | ❑ Visual hallucinations<br> | ||
❑ Auditory hallucinations | ❑ Auditory hallucinations<br> | ||
❑ Tactile hallucinations </div></div> | ❑ Tactile hallucinations </div></div> | ||
---- | ---- | ||
Withdrawal seizures: 24-48 hours | Withdrawal seizures: 24-48 hours<br> | ||
❑ Generalized tonic-clonic seizures | ❑ Generalized tonic-clonic seizures | ||
Alcohol withdrawal delirium ([[delirium tremens]]): 48-72 hours | Alcohol withdrawal delirium ([[delirium tremens]]): 48-72 hours<br> | ||
<div class="mw-collapsible-content"> | <div class="mw-collapsible-content"> | ||
<div class="mw-collapsible mw-collapsed"> | <div class="mw-collapsible mw-collapsed"> | ||
❑ Hallucinations (predominately visual) | ❑ Hallucinations (predominately visual)<br> | ||
❑ Disorientation | ❑ Disorientation<br> | ||
❑ Tachycardia | ❑ Tachycardia<br> | ||
❑ Hypertension | ❑ Hypertension<br> | ||
❑ Low-grade fever | ❑ Low-grade fever<br> | ||
❑ Agitation | ❑ Agitation<Br> | ||
❑ Diaphoresis </div></div> | ❑ Diaphoresis </div></div> | ||
</div>}} | </div>}} | ||
{{familytree | | | | | | | |!| | | | | | | | | }} | {{familytree | | | | | | | |!| | | | | | | | | }} | ||
{{familytree | | | | | | | B01 | | | | | | | | |B01=<div style="float: left; text-align: left; line-height: 150% ">'''Elicit detailed history:''' | {{familytree | | | | | | | B01 | | | | | | | | |B01=<div style="float: left; text-align: left; line-height: 150% ">'''Elicit detailed history:'''<br> | ||
❑ Amount of alcohol intake per day | ❑ Amount of alcohol intake per day<br> | ||
❑ Duration of alcohol use | ❑ Duration of alcohol use<br> | ||
❑ Time since last drink | ❑ Time since last drink<br> | ||
❑ Previous alcohol withdrawals if any | ❑ Previous alcohol withdrawals if any<Br> | ||
❑ Presence of concurrent medical or psychiatric conditions | ❑ Presence of concurrent medical or psychiatric conditions<br> | ||
❑ Abuse of other agents | ❑ Abuse of other agents | ||
---- | ---- | ||
'''Examine the patient:''' | '''Examine the patient:'''<br> | ||
❑ [[Arrhythmias]] | ❑ [[Arrhythmias]]<br> | ||
❑ Signs of [[congestive heart failure]] | ❑ Signs of [[congestive heart failure]]<br> | ||
❑ Signs of [[coronary artery disease]] | ❑ Signs of [[coronary artery disease]]<br> | ||
❑ Signs of [[gastrointestinal bleeding]] | ❑ Signs of [[gastrointestinal bleeding]]<br> | ||
❑ Signs of [[liver disease]] | ❑ Signs of [[liver disease]]<br> | ||
❑ Nervous system impairment | ❑ Nervous system impairment<br> | ||
❑ Signs of [[pancreatitis]] | ❑ Signs of [[pancreatitis]] | ||
</div> }} | </div> }} | ||
{{familytree | | | | | | | |!| | | | | | | }} | {{familytree | | | | | | | |!| | | | | | | }} | ||
{{familytree | | | | | | | C01 | | | | | | |C01=<div style="float: left; text-align: left; line-height: 150% ">'''Order labs:''' | {{familytree | | | | | | | C01 | | | | | | |C01=<div style="float: left; text-align: left; line-height: 150% ">'''Order labs:'''<br> | ||
❑ Complete blood count | ❑ Complete blood count<Br> | ||
❑ Liver function tests | ❑ Liver function tests<br> | ||
❑ Urine drug screen | ❑ Urine drug screen<br> | ||
❑ Blood alcohol levels | ❑ Blood alcohol levels<br> | ||
❑ Electrolyte levels </div>}} | ❑ Electrolyte levels </div>}} | ||
{{familytree | | | | | | | |!| | | | | | | }} | {{familytree | | | | | | | |!| | | | | | | }} | ||
{{familytree | | | | | | | D01 | | | | | | |D01=<div style="float: left; text-align: left; line-height: 150% ">'''Consider alternative diagnosis:''' | {{familytree | | | | | | | D01 | | | | | | |D01=<div style="float: left; text-align: left; line-height: 150% ">'''Consider alternative diagnosis:'''<br> | ||
❑ Thyrotoxicosis | ❑ Thyrotoxicosis<br> | ||
❑ Anticholinergic drug poisoning | ❑ Anticholinergic drug poisoning<br> | ||
❑ Amphetamine or cocaine abuse | ❑ Amphetamine or cocaine abuse<br> | ||
❑ Withdrawal from other sedative-hypnotic agents | ❑ Withdrawal from other sedative-hypnotic agents<br> | ||
❑ Central nervous system infections/Haemorrhage </div>}} | ❑ Central nervous system infections/Haemorrhage </div>}} | ||
{{familytree | | | | | | | | | | | | | | | | }} | {{familytree | | | | | | | | | | | | | | | | }} |
Revision as of 17:43, 9 January 2014
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 defined as an array of signs and symptoms that a chronic alcoholic presents with, when he abruptly ceases alcohol intake. It occurs within 6-48 hours after cessation of alcohol intake.
Diagnostic criteria
A. Sudden reduction/termination in chronic alcohol intake.
B. Two (or more) of the following, developing within several hours to a few days after criterion A:
C. The symptoms in criterion B causing clinically significant impairment of patients social, occupational or other aspects of life.
D. The symptoms cannot be better explained by a general medical condition or other mental disorder.
Assessment of severity of alcohol withdrawal
It is based on "The revised Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar)" scale, and is a 10 item assessment tool that is used to monitor as well as treat patients undergoing withdrawal.
CIWA-Ar scores:
- ≤ 8 points - Mild withdrawal
- 9 to 15 points - Moderate withdrawal
- > 15 points - Severe withdrawal (Associated with increased risk of delirium tremens and seizures)
- ≤ 8 points - Mild withdrawal
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 |
Management
Shown below is an algorithm summarizing the approach to alcohol withdrawal.
Characterize the symptoms: Minor withdrawal symptoms: 6-12 hours ❑ Anorexia Alcoholic hallucinosis: 12-24 hours ❑ Visual hallucinations Withdrawal seizures: 24-48 hours Alcohol withdrawal delirium (delirium tremens): 48-72 hours ❑ Hallucinations (predominately visual) | |||||||||||||||||||||||||||||||||
Elicit detailed history: ❑ Amount of alcohol intake per day Examine the patient: | |||||||||||||||||||||||||||||||||
Order labs: ❑ Complete blood count | |||||||||||||||||||||||||||||||||
Consider alternative diagnosis: ❑ Thyrotoxicosis | |||||||||||||||||||||||||||||||||