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
- Autonomic hyperactivity (e.g., sweating or heart rate > 100 beats/minute)
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[1]
Management
Shown below is an algorithm summarizing the approach to alcohol withdrawal.[2][3]
Characterize the symptoms: Minor withdrawal symptoms: 6-12 hours ❑ Anorexia Alcoholic hallucinosis: 12-24 hours Withdrawal seizures: 24-48 hours Delirium tremens: 48-72 hours | |||||||||||||||||||||||||||||||||||||||||||||||||
Elicit a detailed history: ❑ Amount of alcohol intake per day Examine the patient: | |||||||||||||||||||||||||||||||||||||||||||||||||
Order labs: ❑ Complete blood count | |||||||||||||||||||||||||||||||||||||||||||||||||
Consider alternative diagnosis: ❑ Thyrotoxicosis | |||||||||||||||||||||||||||||||||||||||||||||||||
Assess the 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 | ||||||||||||||||||||||||||||||||||||||||||||||||
Provide general care: ❑ Fluid resuscitation ❑ Supplement thiamine (100 mg IV, before administering glucose) & multivitamins ❑ Correct electrolyte levels ❑ Improve nutrition ❑ Supplement magnesium sulfate if deficient | Provide general care: ❑ Fluid resuscitation ❑ Supplement thiamine (100 mg IV, before administering glucose) & multivitamins ❑ Correct electrolyte levels ❑ Improve nutrition ❑ Supplement magnesium sulfate if deficient ❑ Administer drug therapy:
❑ In case of delirium tremens, higher doses of benzodiazepines (e.g. diazepam 10 mg IV repeated every 2-4 hours if seizure occurs) | ||||||||||||||||||||||||||||||||||||||||||||||||
❑ Monitor patient for at least 24 hours, by assessing CIWA-Ar scale every 4 to 8 hours | If not controlled consider adding an 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) | ||||||||||||||||||||||||||||||||||||||||||||||||
Do's
- Supplement with thiamine before giving IV glucose to prevent development of Wernicke's encephalopathy.
- Use benzodiazepines (BZD's) as the first choice drugs.
- Always prefer longer acting BZD's as they have lesser abuse liability.
- Treat patients with alcohol withdrawal for approximately 7 days unless delirium tremens is present.
- Evaluate patients treated on out-patient basis daily and explain to them when to return to hospital in case of an exacerbation.
Dont's
- Do not use non-BZD's as a single therapy in the treatment of alcohol withdrawal but rather as adjunct treatment in case of failure of the treatment with BZD's.
- Do not use phenytoin to treat alcohol withdrawal seizures.
References
- ↑ American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed., text revision. Washington, D.C.: American Psychiatric Association, 2000:216.
- ↑ Kosten, TR.; O'Connor, PG. (2003). "Management of drug and alcohol withdrawal". N Engl J Med. 348 (18): 1786–95. doi:10.1056/NEJMra020617. PMID 12724485. Unknown parameter
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ignored (help) - ↑ Bayard, M.; McIntyre, J.; Hill, KR.; Woodside, J. (2004). "Alcohol withdrawal syndrome". Am Fam Physician. 69 (6): 1443–50. PMID 15053409. Unknown parameter
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ignored (help)