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]

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
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
  

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

Management

Shown below is an algorithm summarizing the approach to alcohol withdrawal.

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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

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

• 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.

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.