Alcohol withdrawal resident survival guide

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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:

  • 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

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

❑ 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
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider alternative diagnosis:

❑ Thyrotoxicosis ❑ Anticholinergic drug poisoning ❑ Amphetamine or cocaine abuse ❑ Withdrawal from other sedative-hypnotic agents

❑ Central nervous system infections/Haemorrhage
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

References


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