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 hallucinations 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 |
| 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 ❑ Anxiety/Palpitations ❑ Diaphoresis ❑ Gastrointestinal upset ❑ Headache ❑ Insomnia ❑ TremulousnessAlcoholic hallucinosis: 12-24 hours ❑ Visual hallucinations ❑ Auditory hallucinations ❑ Tactile hallucinationsWithdrawal 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 | |||||||||||||||||||||||||||||||||
Consider alternative diagnosis:
❑ Thyrotoxicosis ❑ Anticholinergic drug poisoning ❑ Amphetamine or cocaine abuse ❑ Withdrawal from other sedative-hypnotic agents ❑ Central nervous system infections/Haemorrhage | |||||||||||||||||||||||||||||||||