Alcohol withdrawal resident survival guide: Difference between revisions
No edit summary |
|||
Line 12: | Line 12: | ||
:* Hand [[tremors]]<br> | :* Hand [[tremors]]<br> | ||
:* [[Insomnia]]<br> | :* [[Insomnia]]<br> | ||
:* Gastrointestinal upset ( | :* Gastrointestinal upset (nausea or vomiting)<br> | ||
:* Transient visual, tactile, or auditory hallucinations or illusions<br> | :* Transient visual, tactile, or auditory [[hallucinations]] or [[illusions]]<br> | ||
:* Psychomotor agitation<br> | :* Psychomotor agitation<br> | ||
:* Anxiety<br> | :* Anxiety<br> | ||
Line 27: | Line 27: | ||
:* ≤ 8 points - Mild withdrawal <br> | :* ≤ 8 points - Mild withdrawal <br> | ||
:* 9 to 15 points - Moderate withdrawal <br> | :* 9 to 15 points - Moderate withdrawal <br> | ||
:* > 15 points - Severe withdrawal (Associated with increased risk of delirium tremens and seizures) | :* > 15 points - Severe withdrawal (Associated with increased risk of [[delirium tremens]] and seizures) | ||
Line 256: | Line 256: | ||
<div class="mw-collapsible-content"> | <div class="mw-collapsible-content"> | ||
<div class="mw-collapsible mw-collapsed"> | <div class="mw-collapsible mw-collapsed"> | ||
❑ Anorexia<br> | ❑ [[Anorexia]]<br> | ||
❑ Anxiety/Palpitations<br> | ❑ [[Anxiety]]/[[Palpitations]]<br> | ||
❑ Diaphoresis<br> | ❑ [[Diaphoresis]]<br> | ||
❑ Gastrointestinal upset<br> | ❑ Gastrointestinal upset<br> | ||
❑ Headache<br> | ❑ Headache<br> | ||
❑ Insomnia<br> | ❑ [[Insomnia]]<br> | ||
❑ Tremulousness </div></div> | ❑ [[Tremulousness]] </div></div> | ||
---- | ---- | ||
Alcoholic hallucinosis: 12-24 hours<br> | Alcoholic hallucinosis: 12-24 hours<br> | ||
Line 272: | Line 272: | ||
---- | ---- | ||
Withdrawal seizures: 24-48 hours<br> | Withdrawal seizures: 24-48 hours<br> | ||
❑ Generalized tonic-clonic seizures | ❑ [[Generalized tonic-clonic seizures]] | ||
---- | ---- | ||
Alcohol withdrawal delirium ([[delirium tremens]]): 48-72 hours<br> | Alcohol withdrawal delirium ([[delirium tremens]]): 48-72 hours<br> | ||
Line 313: | Line 313: | ||
{{familytree | | | | | | | D01 | | | | | | |D01=<div style="float: left; text-align: left; line-height: 150% ">'''Consider alternative diagnosis:'''<br> | {{familytree | | | | | | | D01 | | | | | | |D01=<div style="float: left; text-align: left; line-height: 150% ">'''Consider alternative diagnosis:'''<br> | ||
❑ [[Thyrotoxicosis]]<br> | ❑ [[Thyrotoxicosis]]<br> | ||
❑ Anticholinergic drug poisoning<br> | ❑ [[Anticholinergic]] drug poisoning<br> | ||
❑ [[Amphetamine]] or [[cocaine]] abuse<br> | ❑ [[Amphetamine]] or [[cocaine]] abuse<br> | ||
❑ Withdrawal from other sedative-hypnotic agents<br> | ❑ Withdrawal from other sedative-hypnotic agents<br> | ||
Line 326: | Line 326: | ||
{{familytree | | | H01 | | | | | | H02 | | | | | | | |H01=<div style="float: left; text-align: left; line-height: 150% "> '''General care:''' <br> ❑ Fluid resusication <br> ❑ Correct electrolyte levels <br> ❑ Improve nutrition <br> ❑ Supplement magnesium sulfate if deficient <br> ❑ Supplement thiamine (100 mg IV) & multivitamins | {{familytree | | | H01 | | | | | | H02 | | | | | | | |H01=<div style="float: left; text-align: left; line-height: 150% "> '''General care:''' <br> ❑ Fluid resusication <br> ❑ Correct electrolyte levels <br> ❑ Improve nutrition <br> ❑ Supplement magnesium sulfate if deficient <br> ❑ Supplement thiamine (100 mg IV) & multivitamins | ||
---- | ---- | ||
❑ Monitor patient for atleast 24 hours, by assessing CIWA-Ar scale ( < 8) every 4 to 8 hours.</div> |H02=<div style="float: left; text-align: left; line-height: 150% "> '''General care:''' <br> ❑ Fluid | ❑ Monitor patient for atleast 24 hours, by assessing CIWA-Ar scale ( < 8) every 4 to 8 hours.</div> |H02=<div style="float: left; text-align: left; line-height: 150% "> '''General care:''' <br> ❑ Fluid resuscitation <br> ❑ Correct electrolyte levels <br> ❑ Improve nutrition <br> ❑ Supplement magnesium sulfate if deficient <br> ❑ Supplement thiamine (100 mg IV) & multivitamins | ||
---- | ---- | ||
'''Drug therapy:'''<br> | '''Drug therapy:'''<br> | ||
Line 332: | Line 332: | ||
<tr class="v-firstrow"><th>Symptom triggered regimen (Better)</th><th>Fixed schedule regimen</th></tr> | <tr class="v-firstrow"><th>Symptom triggered regimen (Better)</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>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>[[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>[[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> | <tr><td>[[Lorazepam]] 2 - 4 mg</td><td>Lorazepam 4 doses of 2 mg, then 8 doses of 1 mg </td></tr> | ||
</table> </div> | </table> </div> | ||
---- | ---- | ||
<div style="float: left; text-align: left; line-height: 150% ">If not controlled consider <br> '''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 (seizure control only) | <div style="float: left; text-align: left; line-height: 150% ">If not controlled consider <br> '''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) | ||
---- | ---- | ||
'''Delirium tremens treatment:''' <br> ❑ Higher doses of [[benzodiazepines]] (e.g. diazepam 10 mg IV repeated 2 hourly if seizure occurs) </div> }} | '''Delirium tremens treatment:''' <br> ❑ Higher doses of [[benzodiazepines]] (e.g. diazepam 10 mg IV repeated 2 hourly if seizure occurs) </div> }} |
Revision as of 00:57, 10 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:
- Autonomic hyperactivity (e.g., sweating or pulse rate > than 100/minute)
- Hand tremors
- Insomnia
- Gastrointestinal upset (nausea or vomiting)
- Transient visual, tactile, or auditory hallucinations or illusions
- Psychomotor agitation
- Anxiety
- Grand mal seizures
- Autonomic hyperactivity (e.g., sweating or pulse rate > than 100/minute)
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 | |||||||||||||||||||||||||||||||||||||||||||||||||
Assess 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 | ||||||||||||||||||||||||||||||||||||||||||||||||
General care: ❑ Fluid resusication ❑ Correct electrolyte levels ❑ Improve nutrition ❑ Supplement magnesium sulfate if deficient ❑ Supplement thiamine (100 mg IV) & multivitamins ❑ Monitor patient for atleast 24 hours, by assessing CIWA-Ar scale ( < 8) every 4 to 8 hours. | General care:
❑ Fluid resuscitation ❑ Correct electrolyte levels ❑ Improve nutrition ❑ Supplement magnesium sulfate if deficient ❑ Supplement thiamine (100 mg IV) & multivitamins Drug therapy:
If not controlled consider 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) Delirium tremens treatment: ❑ Higher doses of benzodiazepines (e.g. diazepam 10 mg IV repeated 2 hourly if seizure occurs) | ||||||||||||||||||||||||||||||||||||||||||||||||