Alcohol withdrawal resident survival guide: Difference between revisions
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===Do's=== | |||
* Supplement thiamine before giving IV glucose to prevent development of [[Wernicke's encephalopathy]]. | |||
* Benzodiazepines (BZD's) are considered first choice drugs. | |||
* The usual period of treatment is around 7 days, if delirium tremens is not the presentation. | |||
* Patients being treated on out-patient basis must be evaluated daily and explained when to return to hospital, in case of exacerbation. | |||
* Always prefer longer acting BZD's as they have lesser abuse liability. | |||
* Phenobarbital has a poorer safety profile compared to BZD's. | |||
===Dont's=== | |||
* Do not use non-BZD's as single therapy, used only as adjunct treatment. | |||
* Phenytoin has no primary role in the treatment of alcohol withdrawal symptoms. | |||
==References== | ==References== |
Revision as of 01:10, 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) | ||||||||||||||||||||||||||||||||||||||||||||||||
Do's
- Supplement thiamine before giving IV glucose to prevent development of Wernicke's encephalopathy.
- Benzodiazepines (BZD's) are considered first choice drugs.
- The usual period of treatment is around 7 days, if delirium tremens is not the presentation.
- Patients being treated on out-patient basis must be evaluated daily and explained when to return to hospital, in case of exacerbation.
- Always prefer longer acting BZD's as they have lesser abuse liability.
- Phenobarbital has a poorer safety profile compared to BZD's.
Dont's
- Do not use non-BZD's as single therapy, used only as adjunct treatment.
- Phenytoin has no primary role in the treatment of alcohol withdrawal symptoms.