Alcohol withdrawal resident survival guide: Difference between revisions
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==Definition== | C==Definition== | ||
Alcohol withdrawal is | 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=== | ===Diagnostic criteria=== | ||
A. Sudden reduction | A. Sudden reduction or termination in chronic alcohol intake<br> | ||
B. Two (or more) of the following, developing within several hours to a few days after | B. Two (or more) of the following, developing within several hours to a few days after alcohol intake reduction or termination:<br> | ||
:* Autonomic hyperactivity (e.g., sweating or pulse rate > than 100/minute)<br> | :* Autonomic hyperactivity (e.g., sweating or pulse rate > than 100/minute)<br> | ||
:* Hand [[tremors]]<br> | :* Hand [[tremors]]<br> | ||
:* [[Insomnia]]<br> | :* [[Insomnia]]<br> | ||
:* Gastrointestinal upset (nausea or vomiting)<br> | :* Gastrointestinal upset (nausea or vomiting)<br> | ||
:* Transient visual, tactile, or auditory [[hallucinations]] or | :* Transient visual, tactile, or auditory [[hallucinations]] or illusions<br> | ||
:* Psychomotor agitation<br> | :* Psychomotor agitation<br> | ||
:* Anxiety<br> | :* Anxiety<br> | ||
:* Grand mal seizures<br> | :* Grand mal seizures<br> | ||
C. | C. Clinically significant impairment of the patient's social, occupational or other aspects of life due to the symptoms in criterion B <br> | ||
D. | D. Absence of a better explanation of the symptoms in criterion B by a general medical condition or other mental disorder | ||
===Assessment of | ===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. | |||
CIWA-Ar scores: <br> | CIWA-Ar scores: <br> | ||
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==Management== | ==Management== |
Revision as of 03:15, 15 January 2014
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Vidit Bhargava, M.B.B.S [2]
C==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 in chronic alcohol intake
B. Two (or more) of the following, developing within several hours to a few days after alcohol intake reduction or termination:
- Autonomic hyperactivity (e.g., sweating or pulse rate > than 100/minute)
- Hand tremors
- Insomnia
- Gastrointestinal upset (nausea or vomiting)
- Transient visual, tactile, or auditory hallucinations or illusions
- Psychomotor agitation
- Anxiety
- Grand mal seizures
- Autonomic hyperactivity (e.g., sweating or pulse rate > than 100/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
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.
CIWA-Ar scores:
- ≤ 8 points - Mild withdrawal
- 9 to 15 points - Moderate withdrawal
- > 15 points - Severe withdrawal (Associated with increased risk of delirium tremens and seizures)
- ≤ 8 points - Mild withdrawal
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 Alcoholic hallucinosis: 12-24 hours ❑ Visual hallucinations Withdrawal seizures: 24-48 hours Alcohol withdrawal delirium (delirium tremens): 48-72 hours ❑ Hallucinations (predominately visual) | |||||||||||||||||||||||||||||||||||||||||||||||||
Elicit detailed history: ❑ Amount of alcohol intake per day Examine the patient: | |||||||||||||||||||||||||||||||||||||||||||||||||
Order labs: ❑ Complete blood count | |||||||||||||||||||||||||||||||||||||||||||||||||
Consider alternative diagnosis: ❑ Thyrotoxicosis | |||||||||||||||||||||||||||||||||||||||||||||||||
Assess 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 | ||||||||||||||||||||||||||||||||||||||||||||||||
General care: ❑ Fluid resusication ❑ Correct electrolyte levels ❑ Improve nutrition ❑ Supplement magnesium sulfate if deficient ❑ Supplement thiamine (100 mg IV) & multivitamins ❑ Monitor patient for atleast 24 hours, by assessing CIWA-Ar scale ( < 8) every 4 to 8 hours. | General care:
❑ Fluid resuscitation ❑ Correct electrolyte levels ❑ Improve nutrition ❑ Supplement magnesium sulfate if deficient ❑ Supplement thiamine (100 mg IV) & multivitamins Drug therapy:
If not controlled consider 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) Delirium tremens treatment: ❑ Higher doses of benzodiazepines (e.g. diazepam 10 mg IV repeated 2 hourly if seizure occurs) | ||||||||||||||||||||||||||||||||||||||||||||||||
The following guidelines are based on "American association of family physician" and "New england journal of medicine" guidelines. [1] [2]
Do's
- Supplement thiamine before giving IV glucose to prevent development of Wernicke's encephalopathy.
- Benzodiazepines (BZD's) are considered first choice drugs.
- The usual period of treatment is around 7 days, if delirium tremens is not the presentation.
- Patients being treated on out-patient basis must be evaluated daily and explained when to return to hospital, in case of exacerbation.
- Always prefer longer acting BZD's as they have lesser abuse liability.
- Phenobarbital has a poorer safety profile compared to BZD's.
Dont's
- Do not use non-BZD's as single therapy, used only as adjunct treatment.
- Phenytoin has no primary role in the treatment of alcohol withdrawal symptoms.
References
- ↑ 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)