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 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
  

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.

• 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

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 Delirium tremens: 48-72 hours ❑ Hallucinations (predominately visual) ❑ Disorientation ❑ Tachycardia ❑ Hypertension ❑ Low-grade fever ❑ Agitation ❑ Diaphoresis

Elicit a 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 substances 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 ❑ Electrolytes levels

Consider alternative diagnosis: ❑ Thyrotoxicosis ❑ Anticholinergic drug poisoning ❑ Amphetamine or cocaine abuse ❑ Withdrawal from other sedative-hypnotic agents ❑ Central nervous system infections/hemorrhage

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

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: Symptom triggered regimen (Better) Fixed schedule regimen Treat with one of the following every hour till CIWA-Ar falls below 8 Treat with one of the following every 6 hours till CIWA-Ar falls below 8 Chlordiazepoxide 50 - 100 mg or Chlordiazepoxide 4 doses of 50 mg, then 8 doses of 25 mg Diazepam 10 - 20 mg Diazepam 4 doses of 10 mg, then 8 doses of 5 mg Lorazepam 2 - 4 mg Lorazepam 4 doses of 2 mg, then 8 doses of 1 mg 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)

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.