Alcohol withdrawal

Alcohol withdrawal

Apr 9, 2015 0
General medicine,general surgery,onthepods,toxicology

James talks to Professor Kate Conigrave about alcohol withdrawal on the wards.

Script Writer:  Duncan Campbell

Summary Writer:  Duncan Campbell

Editor:  James Edwards

Interviewee:  Kate Conigrave

About Kate Conigrave

Kate Conigrave is an addiction medicine specialist and public health physician. She works as a senior staff specialist at Royal Prince Alfred Hospital. There, she is involved in both inpatient and outpatient treatment for alcohol or drug use disorders.

Kate is also a conjoint Professor at the University of Sydney and has acted as an editor of two clinical texts “Addiction Medicine”, published by Oxford University Press and “The Handbook for Aboriginal Alcohol and Drug Work”, published by the University of Sydney. She has published over 100 papers in peer-reviewed journals and has received the Senior Scientist Award of the Australasian Professional Society on Alcohol and other Drugs.

Alcohol Withdrawal

With Professor Kate Conigrave, Staff Specialist in Addiction Medicine, Royal Prince Alfred Hospital, New South Wales, Australia

Case

You are a junior doctor working after hours when you receive a phone call from a nurse who is worried about a patient that may be withdrawing from alcohol.

  • How long has the patient been in hospital? (If > 2 weeks, unlikely to be alcohol withdrawal)
  • Could you please do an alcohol withdrawal scale?
  • Have they had a seizure?
  • Do they have IV access?
  • History:
    • When was the patient’s last drink? (If > 1 week ago, unlikely to be alcohol withdrawal)
    • How often do they drink?
    • How much do they drink on each occasion? (Typically need to drink > 6 drinks to withdraw from alcohol)
    • Do they have any alcohol-free days? (If they have alcohol-free days, unlikely to be withdrawal)
    • What is their withdrawal usually like? (patients usually have similar patterns of withdrawal)
    • If they have never stopped drinking before, what is it usually like in the morning before their first drink? Shakes?
    • Have they had a seizure before?
  • Examination:
    • Observations
  • Expect slight tachycardia, hypertension or fever to 38.5 C
    • General examination
  • Is the patient relaxed or agitated? (patients in alcohol withdrawal are usually restless and agitated during the day and trouble sleeping at night)
    • Assess the patient’s hands
  • Are they dry or sweaty? (patients in alcohol withdrawal typically have sweaty hands)
  • Anchor the patient’s elbows on the bed and ask them to extend their forearms to assess for hand tremor (patients in alcohol withdrawal typically have a fine tremor, in contrast with a cerebellar tremor which is typically coarse)
    • Assess for other causes of restlessness or confusion common in alcoholics, such as infection, lung disease, head injury
  • Benzo withdrawal and alcohol withdrawal are very similar
  • Ask the patient if they take any pills
  • If the patient is withdrawing from both, expect a more severe withdrawal
  • Alcohol withdrawal scale
  • Electrolytes, FBC (including platelets which are often low in liver failure)
  • Magnesium (hypomagnesaemia can lower seizure threshold)
  • BSL
  • INR (as a measure of hepatic synthetic function)
  • If mild-moderate withdrawal (e.g. ~12 drinks per day) chart diazepam on a sliding scale PRN
    • Measure AWS every 4 hours
    • If AWS 4-5, give diazepam 10 mg PO
    • If AWS 6+, give diazepam 20 mg PO
    • Feel free to adjust certain criteria on the AWS, for instance if you know that the patient has an infection that is causing fever rather than alcohol withdrawal, you can adjust the temperature criterion so that it is worth one less point
  • If severe withdrawal (e.g. profound diaphoresis and tremor, AWS 6+ when first assessed) chart regular diazepam after an initial stat dose
    • Stat dose of diazepam 20 mg PO
    • Diazepam 10 mg PO QID
    • AND q4 hourly AWS with diazepam on sliding scale PRN as above
    • NOTE: this protocol should also be used for someone at high risk of severe withdrawal, before the withdrawal actually starts (e.g. 2L wine per day, previous complicated withdrawal including delirium tremens)
  • Substitute oxazepam for diazepam (5 mg diazepam PO = 15 mg oxazepam PO)
  • NOTE: you should also use oxazepam instead of diazepam for patients with respiratory failure or in elderly patients
  • Delirium tremens
  • Acute delirium in the context of alcohol withdrawal
  • The most severe type on the spectrum of alcohol withdrawal
  • Typically occurs on day 2-4 of alcohol withdrawal
  • Occurs with other signs of withdrawal including tremor, agitation, tachycardia, hypertension, fever
  • If there are no other signs of alcohol withdrawal, the delirium is likely to be of a different cause!
  • Diagnosis is made in someone who is a heavy drinker and has one of the triad of signs including:
    • Confusion
    • Ophthalmoplegia (paralysis of lateral gaze, nystagmus)
    • Cerebellar signs (ataxia)
  • Management is safe and must be commenced in anyone at risk of developing the syndrome
    • Do not give glucose until thiamine has been given!
    • Give thiamine: at least 100 mg TDS IV and up to 500 mg TDS IV
  • If it doesn’t add up, or if worried about delirium tremens or Wernicke’s, call for help!
  • Commence treatment early for severe withdrawal to prevent delirium tremens
  • When charting regular diazepam, consider writing ‘withhold if sedated’
  • Once the alcohol withdrawal is under control, wean diazepam by approximately 10 mg per day
  • Once withdrawal is complete, liaise with the drug and alcohol team to arrange appropriate outpatient follow up

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Tags: #addiction medicine,#alcohol use,#alcohol withdrawal,#benzodiazepines,#benzos,#delirium tremens,#diazepam,#Drug and Alcohol Dependence,#drugs and alcohol,#DTs,#Wernicke’s encephalopathy

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