Alcohol withdrawal resident survival guide: Difference between revisions
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{{WikiDoc CMG}}; {{AE}} {{VB}} | {{WikiDoc CMG}}; {{AE}} {{VB}} | ||
== | ==Overview== | ||
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. | 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<br> | A. Sudden reduction or termination of chronic alcohol intake<br> | ||
Line 18: | Line 18: | ||
:* [[Grand mal seizures]]<br> | :* [[Grand mal seizures]]<br> | ||
C. Clinically significant impairment of the patient's social, occupational or other aspects of life due to the symptoms in criterion B <br> | C. Clinically significant impairment of the patient's social, occupational or other aspects of life due to the symptoms in criterion B <br> | ||
D. Absence of a better explanation of the symptoms in criterion B by a general medical condition or other mental disorder | D. Absence of a better explanation of the symptoms in criterion B by a general medical condition or other mental disorder<ref>American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed., text revision. Washington, D.C.: American Psychiatric Association, 2000:216.</ref> | ||
== | ==[[Alcohol Withdrawal Calculator]]== | ||
==Management== | |||
Shown below is an algorithm summarizing the approach to alcohol withdrawal.<ref name="Kosten-2003">{{Cite journal | last1 = Kosten | first1 = TR. | last2 = O'Connor | first2 = PG. | title = Management of drug and alcohol withdrawal. | journal = N Engl J Med | volume = 348 | issue = 18 | pages = 1786-95 | month = May | year = 2003 | doi = 10.1056/NEJMra020617 | PMID = 12724485 }}</ref><ref name="Bayard-2004">{{Cite journal | last1 = Bayard | first1 = M. | last2 = McIntyre | first2 = J. | last3 = Hill | first3 = KR. | last4 = Woodside | first4 = J. | title = Alcohol withdrawal syndrome. | journal = Am Fam Physician | volume = 69 | issue = 6 | pages = 1443-50 | month = Mar | year = 2004 | doi = | PMID = 15053409 }}</ref> | |||
{{chart/start |summary=PE diagnosis Algorithm.}} | |||
{{chart | | | | | | | FOO | |FOO=<div style="text-align: left; line-height: 150% ">'''Characterize the symptoms:'''<br><br> '''Minor withdrawal symptoms: 6-12 hours'''<br> | |||
❑ [[Anorexia]]<br> | |||
❑ [[Anxiety]]/[[Palpitations]]<br> | |||
❑ [[Diaphoresis]]<br> | |||
❑ Gastrointestinal upset<br> | |||
❑ [[Headache]]<br> | |||
❑ [[Insomnia]]<br> | |||
---- | |||
'''Alcoholic hallucinosis: 12-24 hours'''<br> | |||
❑ Visual hallucinations<br> | |||
❑ Auditory hallucinations<br> | |||
❑ Tactile hallucinations | |||
---- | |||
'''Withdrawal seizures: 24-48 hours'''<br> | |||
❑ [[Generalized tonic-clonic seizures]] | |||
---- | |||
'''Delirium tremens: 48-72 hours'''<br> | |||
❑ [[Hallucination]]s (predominately visual)<br> | |||
❑ Disorientation<br> | |||
❑ [[Tachycardia]]<br> | |||
❑ [[Hypertension]]<br> | |||
❑ Low-grade [[fever]]<br> | |||
❑ Agitation<Br> | |||
❑ [[Diaphoresis]]</div>}} | |||
{{chart | | | | | | | |!| | | | | | | | | }} | |||
{{chart | | | | | | | BAR | | | | | | | | |BAR=<div style="text-align: left; line-height: 150% ">'''Obtain a detailed history:'''<br> | |||
❑ Amount of alcohol intake per day<br> | |||
❑ Duration of alcohol use<br> | |||
❑ Time since last drink<br> | |||
❑ Previous alcohol withdrawals if any<Br> | |||
❑ Presence of concurrent medical or psychiatric conditions<br> | |||
❑ Abuse of other substances | |||
---- | |||
'''Examine the patient:'''<br> | |||
❑ [[Arrhythmias]]<br> | |||
❑ Signs of [[congestive heart failure]]<br> | |||
❑ Signs of [[coronary artery disease]]<br> | |||
❑ Signs of [[gastrointestinal bleeding]]<br> | |||
❑ Signs of [[liver disease]]<br> | |||
❑ Nervous system impairment<br> | |||
❑ Signs of [[pancreatitis]] | |||
</div> }} | |||
{{chart | | | | | | | |!| | | | | | | }} | |||
{{chart | | | | | | | CZERO | | | | | | |CZERO=<div style="text-align: left; line-height: 150% ">'''Order labs:'''<br> | |||
❑ [[CBC|Complete blood count]]<br> | |||
❑ [[LFT|Liver function tests]]<br> | |||
❑ Urine drug screen<br> | |||
❑ Blood alcohol levels<br> | |||
❑ [[Electrolyte]]s levels </div>}} | |||
{{chart | | | | | | | |!| | | | | | | }} | |||
{{chart | | | | | | | DZERO | | | | | | |DZERO=<div style="text-align: left; line-height: 150% ">'''Consider alternative diagnosis:'''<br> | |||
❑ [[Thyrotoxicosis]]<br> | |||
❑ [[Anticholinergic]] drug poisoning<br> | |||
❑ [[Amphetamine]] or [[cocaine]] abuse<br> | |||
❑ Withdrawal from other sedative-hypnotic agents<br> | |||
❑ Central nervous system infections/hemorrhage </div>}} | |||
{{chart | | | | | | | |!| | | | | | | | }} | |||
{{chart | | | | | | | EZERO | | | | | | | | |EZERO= '''[[Alcohol withdrawal resident survival guide#Assessment of Severity of Alcohol Withdrawal|Assess the severity of withdrawal based on CIWA-Ar scale]]'''}} | |||
{{chart | | | |,|-|-|-|^|-|-|-|.| | | | | }} | |||
{{chart | | | FZO | | | | | | FZT | | | | |FZO='''Mild withdrawal''' |FZT=<div style="text-align: left; line-height: 150% ">'''Moderate to severe withdrawal or any one of the following:''' <br> ❑ Past history of severe withdrawal symptoms <br> ❑ History of withdrawal seizures or [[delirium tremens]] <br> ❑ Multiple previous detoxifications <br> ❑ Concomitant psychiatric or medical illness <br> ❑ Recent high levels of alcohol consumption <br> ❑ Pregnancy <br> ❑ Lack of a reliable support network </div> }} | |||
{{chart | | | |!| | | | | | | |!| | | | | | | | | }} | |||
{{chart | | | GZO | | | | | | GZT | | | | | | | |GZO= '''Out-patient treatment''' |GZT= '''In-patient treatment''' }} | |||
{{chart | | | |!| | | | | | | |!| | | | | | | | | }} | |||
{{chart | | | HZO | | | | | | HZT | | | | | | | |HZO=<div style="text-align: left; line-height: 150% "> '''Provide general care:''' <br> ❑ Fluid resuscitation <br> ❑ Supplement thiamine (100 mg IV, before administering glucose) & multivitamins<br> ❑ Correct electrolyte levels <br> ❑ Improve nutrition <br> ❑ Supplement magnesium sulfate if deficient </div> |HZT=<div style="text-align: left; line-height: 150% "> '''Provide general care:''' <br> ❑ Fluid resuscitation <br> ❑ Supplement thiamine (100 mg IV, before administering glucose) & multivitamins <br> ❑ Correct electrolyte levels <br> ❑ Improve nutrition <br> ❑ Supplement magnesium sulfate if deficient | |||
---- | |||
❑ '''Administer drug therapy:'''<br> | |||
<table class="wikitable"> | |||
<tr class="v-firstrow"><th>Symptom triggered regimen (Preferred)</th><th>Fixed schedule regimen</th></tr> | |||
<tr><td>Treat with one of the following every hour till CIWA-Ar falls below 8</td><td> Treat with one of the following every 6 hours till CIWA-Ar falls below 8</td></tr> | |||
<tr><td>[[Chlordiazepoxide]] 50 - 100 mg or</td><td> Chlordiazepoxide 4 doses of 50 mg, then 8 doses of 25 mg</td></tr> | |||
<tr><td>[[Diazepam]] 10 - 20 mg</td><td>Diazepam 4 doses of 10 mg, then 8 doses of 5 mg</td></tr> | |||
<tr><td>[[Lorazepam]] 2 - 4 mg</td><td>Lorazepam 4 doses of 2 mg, then 8 doses of 1 mg </td></tr> | |||
</table> <br> | |||
❑ In case of [[delirium tremens]], higher doses of [[benzodiazepines]] (e.g. diazepam 10 mg IV repeated every 2-4 hours if seizure occurs)</div>}} | |||
{{chart | | | |!| | | | | | | |!| | | | | | | | | }} | |||
{{chart | | | IZO | | | | | | IZT | | | | | | | | IZO= ❑ Monitor patient for at least 24 hours, by assessing CIWA-Ar scale every 4 to 8 hours| IZT= <div style="text-align: left; line-height: 150% ">'''If not controlled consider adding an adjunct therapy with 1 or more of the following:''' <br> ❑ [[Phenothiazines]] <br> ❑ [[Haloperidol]] (reduces seizure threshold) <br> ❑ [[Beta blockers]] (esp in those with coronary disease) <br> ❑ [[Clonidine]] <br> ❑ [[Carbamazepine]]/[[phenytoin]] (seizure control only)</div>}} | |||
{{chart/end}} | |||
<br> | |||
==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: | * The interpretation of the CIWA-Ar scores is as follows: | ||
:* ≤ 8 points: Mild withdrawal | :* ≤ 8 points: Mild withdrawal | ||
:* 9 to 15 points: Moderate withdrawal | :* 9 to 15 points: Moderate withdrawal | ||
:* > 15 points: Severe withdrawal, associated with increased risk of [[delirium tremens]] and seizures | :* > 15 points: Severe withdrawal, associated with increased risk of [[delirium tremens]] and seizures<ref name="Sullivan-1989">{{Cite journal | last1 = Sullivan | first1 = JT. | last2 = Sykora | first2 = K. | last3 = Schneiderman | first3 = J. | last4 = Naranjo | first4 = CA. | last5 = Sellers | first5 = EM. | title = Assessment of alcohol withdrawal: the revised clinical institute withdrawal assessment for alcohol scale (CIWA-Ar). | journal = Br J Addict | volume = 84 | issue = 11 | pages = 1353-7 | month = Nov | year = 1989 | doi = | PMID = 2597811 }}</ref> | ||
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| Disorientated for place and/or person | | Disorientated for place and/or person | ||
| - | |||
| - | |||
| - | |||
|- | |- | ||
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|} | |} | ||
Click [[Alcohol withdrawal#Alcohol Withdrawal Calculator|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. | * Use [[benzodiazepines]] (BZD's) as the first choice drugs. | ||
* Always prefer longer acting BZD's as they have | * 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. | * 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. | * 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.<ref name="www.who.int">{{Cite web | last = | first = | title = WHO | Management of alcohol withdrawal | url = http://www.who.int/mental_health/mhgap/evidence/alcohol/q2/en/ | publisher = | date = | accessdate = 15 January 2014 }}</ref> | |||
==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 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 alcohol withdrawal [[seizures]]. | * 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.<ref name="www.who.int">{{Cite web | last = | first = | title = WHO | Management of alcohol withdrawal | url = http://www.who.int/mental_health/mhgap/evidence/alcohol/q2/en/ | publisher = | date = | accessdate = 15 January 2014 }}</ref> | |||
==References== | ==References== |
Latest revision as of 00:28, 13 March 2014
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Vidit Bhargava, M.B.B.S [2]
Overview
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]
Alcohol Withdrawal Calculator
Management
Shown below is an algorithm summarizing the approach to alcohol withdrawal.[2][3]
Template:Chart/cell^tTemplate:Chart/cell^bCharacterize the symptoms: Minor withdrawal symptoms: 6-12 hours ❑ Anorexia Alcoholic hallucinosis: 12-24 hours Withdrawal seizures: 24-48 hours Delirium tremens: 48-72 hours | |||||||||||||||||||||||||||||||||||||||||||||||||
Obtain 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) | ||||||||||||||||||||||||||||||||||||||||||||||||
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[4]
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.[5]
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.[5]
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
|month=
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
|month=
ignored (help) - ↑ Sullivan, JT.; Sykora, K.; Schneiderman, J.; Naranjo, CA.; Sellers, EM. (1989). "Assessment of alcohol withdrawal: the revised clinical institute withdrawal assessment for alcohol scale (CIWA-Ar)". Br J Addict. 84 (11): 1353–7. PMID 2597811. Unknown parameter
|month=
ignored (help) - ↑ 5.0 5.1 "WHO". Retrieved 15 January 2014. Text " Management of alcohol withdrawal " ignored (help)