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 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: 1. Autonomic hyperactivity (e.g., sweating or pulse rate > than 100/minute) 2. Hand tremors 3. Insomnia 4. Gastrointestinal upset (Nausea or vomiting) 5. Transient visual, tactile, or auditory hallucination s or illusions 6. Psychomotor agitation 7. Anxiety 8. Grand mal seizures 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 - to 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

Management

Shown below is an algorithm summarizing the approach to [[Alcohol withdrawal]].

Characterize the symptoms: Minor withdrawal symptoms: 6-12 hours ❑ Anorexia ❑ Anxiety/Palpitations ❑ Diaphoresis ❑ Gastrointestinal upset ❑ Headache ❑ Insomnia ❑ Tremulousness Alcoholic hallucinosis: 12-24 hours ❑ Visual hallucinations ❑ Auditory hallucinations ❑ Tactile hallucinations Withdrawal seizures: 24-48 hours ❑ Generalized tonic-clonic seizures Alcohol withdrawal delirium (delirium tremens): 48-72 hours ❑ Hallucinations (predominately visual) ❑ Disorientation ❑ Tachycardia ❑ Hypertension ❑ Low-grade fever ❑ Agitation ❑ Diaphoresis

Elicit detailed history: ❑ Amount of alcohol intake per day ❑ Duration of alcohol use ❑ Time since last drink ❑ Previous alcohol withdrawals if any ❑ Presence of concurrent medical or psychiatric conditions ❑ Abuse of other agents Examine the patient: ❑ Arrhythmias ❑ Signs of congestive heart failure ❑ Signs of coronary artery disease ❑ Signs of gastrointestinal bleeding ❑ Signs of liver disease ❑ Nervous system impairment ❑ Signs of pancreatitis

Order labs: ❑ Complete blood count ❑ Liver function tests ❑ Urine drug screen ❑ Blood alcohol levels ❑ Electrolyte levels

References

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