Alcohol withdrawal

An unusual topic, but unfortunately very common – especially in the acute patient setting. If detected and treated early, it helps both the patient and the medical team treating patient.

Part One: 

Assess severity (not always done in practice – but good to know that the CIWA tool exists if having doubts on initial dosing.)

Clinical Institute Withdrawal Assessment for Alcohol (CIWA)

 (Severity of alcohol withdrawal)

  1. N+V
  2. Tremor
  3. Paroxysmal sweats
  4. Anxiety
  5. Agitation
  6. Tactile disturbances
  7. Auditory disturbances
  8. Visual disturbances
  9. Headache
  10. Orientation
Symptoms of alcohol withdrawal

 

A quick dosing guide

 

Part Two:

When to treat

  1. Obvious withdrawal
    1. Autonomic hyperactivity (sweating, pulse >100 BPM)
    2. Hand tremor
    3. Psychomotor agitation
  2. Not in withdrawal but a clear history
    1. Drinking >10 units per day
    2. Previous withdrawal
  3. Patient in main ED awaiting medical admission or medical inpatient
  4. Patients in CDU/ awaiting CDU who are suitable for symptom triggered detoxification

Points 2 and 3 may be the ones you come across the most as an NCHD in an acute admission on the ward or in ED.

Part Three:

Treatment (finally!)*

  1. Chlordiazepoxide (Librium) – therapeutic benzodiazepine
    1. 10mg – 20mg QDS (day 1-4)
    2. 10mg – 20mg BD (day 5)
    3. Start initial dose based on severity of withdrawal. Adjust the dose according to the response
  2. Lorazepam if in liver failure
  3. Adjunct treatment
    1. Pabrinex + oral thiamine (Prevent Wernicke-Korsakoff syndrome)
      1.  Pabrinex: I and II in 50-100ml 0.9% NaCl over 30 min IV TDS
      2. Thiamine 100mg PO TDS (usually only for 3/7)
    2. Psychotic symptoms (occurs in Delirium Tremens)
      1. Adjust Librium
      2. Add Haloperidol 0.5-5mg PO QID/PRN
    3. If acutely disturbed/violent behaviour (IV or IM)
      1. Lorazepam or Midazolam

Part Four:

Observation:

  1. Vital signs
  2. Level of arousal
    1. Drowsiness is not a symptom of withdrawal.
    2. If drowsy, Librium dose should be lowered
  3. Severity of withdrawal via the CIWA-Ar Scale

 

I hope this helps provide a quick guide to effectively dealing with alcohol withdrawal in a hospital inpatient. Part three should serve as a concise treatment regimen that can be remembered and used by the junior doctor in a hospital setting.

*Of course dosing and indeed different variations of drugs may be used in different countries (i.e. Diazepam used instead of Librium in Australia)

 

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