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