Alcohol Withdrawal

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Definition

-  Syndrome of neurological excitation due to withdrawal effects of chronic alcohol ingestion

 

Features

-  Ulikely to occur if intake < 6 standard drinks/day

-  If mild S/S peak around 48 hrs

-  If severe S/S peak 4 days or more

 

Associated S/S

-  EtOH Hx

-  Drug Hx

-  Seizure

-  Tonic-clonic

-  2-9% of EtOH dependant persons

-  6-48hrs post last drink

-  Prior to other withdrawal S/S

-  Can occur even if high BAC

-  13-24% risk of recurrence in 6-12/24

-  May indicate severe withdrawal

-  Prevented w prophylactic BZDs (Diazepam)

-  Delerium Tremens (DTs)

-  Acute organic brain syndrome

-  Confusion, disorientatin, agitation, hyperactivity, tremor

-  2-3/7 post last drink, lasts 2-3/7 up to 2/52

-  15% mortality rate

-  Hallucinations

-  Occur at any stage of withdrawal

-  Visual, tactile, auditory

-  +/- paranoid delusions

-  Disturbed affect

 

 

Mx

-  Admission if severe withdrawal or significant co-morbidity

-  Out-pt if safe home enviro, social supports, no Hx DTs or seizures

-  AWS

-  Medication

-  +/- IV fluids

-  Thiamine

-  MUST be given before glucose

-  Prevents Wernickes-Korsakovs

-  Chronic drinkers w poor nutrition status

-   2-300mg IV/IM (beware coagulopathy) for 3-5/7

-   Then 100mg PO TDS for several weeks

-  Good dietary tolerance

-   100mg PO TDS 3-5/7

-   Then 100mg PO Daily 9/7

-  If ? Wernickes use Thiamine 500mg IV TDS 3/7

-  Diazepam

-  In-pt as per AWS

-   Loading dose if high risk for severe withdrawal

-  Diazepam 20mg PO when BAC <0.1% or AWS >10

-  + Diazepam 20mg PO 1/24 until pt sedated

-  If >60mg reassess pt, if >120mg consult D&A

-  Taper dose over 3-5/7

-   If AWS >10 = Diazepam 10-20mg PO 1/24 + monitor 1/24

-   If AWS <10 = monitor 4/24 + Diazepam 5-10mg PO QID PRN

-   If AWS <10 >24hrs cease protocol

-  Out-pt

-   Day 1-3 10mg Diazepam QID

-  + 10mg PRN x2 for days 1-2

-   Day 45 mg BD

-   Days 5-6 5mg NOCTE

-  +/- Haloperidol (antipsychotic)

-   Small doses 2-5mg for hallucinations & agitation if Diazepam ineffective

-   Ensure 60mg Diazepam has been tried as lowers seizure threshold

-  +/- beta blocker: 3rd line

-  Quinine Sulphate 300mg for nocturnal cramps

-  Electrolytes

-  Can be givn prior to U&E

-  Magnesium (Magmin) 1gm PO BD

-  Slow K 1g PO STAT

-  Seizure

-  Diazepam 20mg IV 2/24 untill AWS <5

-  Then typically requires 20mg QID + PRN

-  If uncontrolled call Addiction Specialist

-  DTs

-  Monitor & correct fluids, U&E, CMP

-  Diazepam