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Alcohol Withdrawal Syndromes


Alcoholism: chronic alcohol abuse, dependence, or addiction; chronic excessive ... who abuses or is dependent on alcohol (Stedman's 26th ed.) Alcoholism in the ... – PowerPoint PPT presentation

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Title: Alcohol Withdrawal Syndromes

Alcohol Withdrawal Syndromes
  • By David Bridgers, M.D.

Case Presentation
  • 43 y/o AAM with a hx, HTN, and long term ETOH
    abuse, who presented to the Urology service after
    being seen in the ED for Hematuria, and being
    diagnosed with a renal mass. He was 1 day s/p
    nephrectomy. He was on epidural pain medications
    per pain control. He was reported to be agitated
    when the nursing staff evaluated him.The

Case Presentation
  • The Urology team evaluated the patient and after
    realizing that he had not had a drink in 36 hours
    they called for a Medicine consult for management
    of DTs.

  • Alcoholism chronic alcohol abuse, dependence, or
    addiction chronic excessive drinking of
    alcoholic beverages resulting in impairment of
    health and/or social or occupational functioning,
    and increasing adaptation to the effects of
    alcohol requiring increasing doses to achieve and
    sustain a desired effect specific signs or
    symptoms of withdrawal are usually shown on
    sudden cessation of such drinking.
  • Alcoholic One who suffers from alcoholism. One
    who abuses or is dependent on alcohol (Stedmans
    26th ed.)

Alcoholism in the United States
  • Alcoholism is a common condition, with
    complications that will eventually confront all
  • Estimated 10-18 million Alcoholics in the U.S. in
  • 15-20 of hospitalized and primary care patients.
  • Studies show that b/w 13 and 71 percent of
    patients develop symptoms of ETOH withdrawal

Various Presentations of Acute ETOH Withdrawal
  • Minor Withdrawal Symptoms
  • -occur w/i 6 hours of cessation
  • -insomnia, tremulousness, mild anxiety, GI upset,
    diaphoresis, HA, palpitations, and anorexia.
  • -usually resolve w/i 24-48 hrs.
  • -vary from episode to episode

Various Presentations of Acute ETOH Withdrawal
  • Withdrawal Seizures
  • -w/i 48 hours of last drink
  • -generalized tonic-clonic
  • -3 of chronic alcoholics develop this
  • -3 of those who seize develop Status Epilepticus

Various Presentations of Acute ETOH Withdrawal
  • Alcoholic Hallucinosis
  • - 12- 24 hr. onset after last drink
  • - usually visual
  • - Resolve w/i 24-48 hr.
  • - NOT synonymous with DTs
  • other signs may or may not be present
  • time course is different
  • not usually associated with clouding of the

Various Presentation of Acute ETOH Withdrawal
  • Delirium Tremens
  • - 5 of patients who withdraw
  • - typically begin b/w 48 and 96 hours
  • - typically last 1-5 days
  • - longer periods requiring massive doses of
    medications have been described (Wolf et. Al 1993)

Delirium Tremens
  • - Early figures of associated mortality were as
    high as 37
  • - Now mortality is felt to be 5. This is likely
    due to earlier diagnosis, improved
    pharmacological, and non-pharmocologic
    management, and improved treatment of co-morbid

Delirium Tremens
  • -Mortality risk is greater
  • 1. Elderly
  • 2. Concomitant lung Dz
  • 3. Core body temp 104
  • 4. Co-existing liver Dz.
  • - Death is usually due to arrhythmia or secondary
    complications. (pneumonia,liver failure)

DT Risk Factors
  • History of sustained drinking
  • Previous DTs
  • 30
  • Greater number of days since last drink
  • Presence of other illnesses

Hallmarks of DTs
  • Hallucinations
  • Disorientation
  • Tachycardia
  • Hypertension
  • Low Grade Fever
  • Agitation
  • Diaphoresis

Hallmarks of DTs
  • Elevated cardiac indices, oxygen delivery and
    oxygen consumption
  • Hyperventilation and Respiratory alkalosis which
    result in reduced cerebral blood flow
  • Sensorium Clouding

Other Char. Of Delirium Tremens
  • Fluid and electrolyte concerns
  • Hypokalemia is common
  • Hypomagnesemia - may predispose to sz. Activity
  • Hypophosphatemia - may be present and contribute
    to heart failure and rhabdomyolysis.

Non-Pharmacological Management Principals
  • PT should be closely monitored
  • -Ideally a quiet and protective setting, unless
    pt. Is at higher risk for complications, then
    they should be in a ICU.
  • Frequent evaluation by nursing AND medical staff
  • Other conditions may mimic DT infection, OD,
    trauma, hepatic failure, GIB

Non-Pharmacological Management Principals cont.
  • Appropriate diagnostic testing LP, CMP,
    Cultures etc.
  • Mechanical Restraints in the swimmers position
    for pt. Protection
  • Correction of volume and Electrolyte deficits
  • Thiamine, MVT, Folate given regularly

Pharmacological Management
Pharmacological Management
  • Working Group on Pharmacological Management of
    Alcohol Withdrawal
  • - JAMA July 9,1997
  • - Goal was to establish evidence based
    guidelines for the treatment of Alcohol
    withdrawal syndromes

Working Group Outcomes Studied
  • 1. Severity of withdrawal syndrome
  • 2. Alcohol Withdrawal Delirium
  • 3. Withdrawal Seizures
  • 4. Completion of withdrawal
  • 5. Entry into Rehab
  • 6. Cost

Working Group on ETOH Withdrawal Syndromes cont.
  • Prospective controlled trials with documented
    reporting of the endpoint in question were
    investigated further.
  • Available literature that addressed one of the
    clinical endpoints listed were assimilated and
    reviewed to formulate the pharmacological

  • Clinical Institute Withdrawal Assessment -
    revised version (CIWA-Ar)
  • - Structured Severity Assessment Scale
  • -Objective Scale for use by health care personel
    to evaluate patients at risk for developing
    alcohol withdrawal syndromes, and quantify the
    severity of withdrawal.

  • Well documented reliability, reproducibility, and
    validity when based on comparison with ratings by
    experienced clinicians
  • First used in ETOH detox, and psychiatric units
  • Studies have proven usefulness in general
    medical/surgical wards

  • High scores are predictive of development of
    seizures and delirium!!
  • Scale is currently being used with strict
    protocalls for medication administration at many
    non-teaching facilities
  • Using the CIWA-Ar was found to reduce patient
    effect from over-sedation cost of hospitalization
    by avoiding unnecessary use of medications

Dosing of Pharmacological Agents
  • Dosing Schedules which are acceptable
  • 1. Fixed - most useful in high risk pts.
  • 2. Symptom Triggered - Based on certain
    CIWA-Ar scores.
  • 3. Front Loaded - Auto taper method. Not in
    Working Group Recommendations, but supported by
    other studies

Working Group Recommendations on Choice of Agent
  • -Benzodiazepines recommended
  • 1. Long acting may be more effective in
    controlling seizures
  • 2. Long acting contributes to smoother withdrawal
    and less rebound
  • 3. Short acting have lower risk of oversedation

Working Group on ETOH Withdrawal Syndromes cont
  • 4. Certain Benzos have higher potential for abuse
  • 5. Cost varies considerably

Working Group Recommendations
  • 1. Mild Symptoms (CIWA-Ar score option is non-pharmacological supportive therapy
    and cont. monitoring.
  • Moderate Symptoms (score 8-15) symptomatic
    administration of medications, with hourly
    assessment. Regimen recommended
  • 1.Librium 50-100 mg
  • 2.Valium 10-20 mg
  • 3.Ativan 2-4 mg.

Dosing of Pharmacological Agents
  • Severe Symptoms (score 15) - Provide Fixed
    scheduled medications in the amounts necessary to
    control symptoms. Regimen Recommended
  • 1.Librium50 mg q 6 hrs. x 4 doses then 25 mg q
    6 hrs. x 4 doses
  • 2.Valium 10 mg q 6 hrs. x 4 doses then 5 mg q
    6x 8 doses
  • 3.Ativan 2 mg q 6 x 4 doses then 1 mg q6 x 8
  • Additional PRN dosing if necessary

Dosing of Pharmacological Agents
  • 2. For pts. With a hx of Sz. Provide 1 of the
    proposed fixed regimens on presentation,
    regardless of the severity of withdrawal.
  • (monitoring and symptomatic tx is reasonable)
  • 3. Early treatment of those with severe
    co-morbidities is warranted.

More Recent Evidence on DT Management
  • Pts. In DTs should receive IV diazepam 5-10 mg
    every 5 minutes until pt. Is awake but calm.
  • Continue parenteral administration of Diazepam
    until pt. Is no longer delirious and absorption
    from gut is reliable.

Other Agents Examined
  • Beta Blockers, clonidine, and Carbamazepine - Not
    to be used as mono-therapy because they do not
    protect against delirium or seizures
  • Neuroleptics - Only in conjunction with benzos
    for hallucinations. May increase seizures
  • Magnesium - not recommended
  • Ethyl ETOH - NOT recommended due to lack of
    controlled studies and well known adverse effects
  • Thiamine - Administer at initial evaluation.

Back to Our Case
  • Pt. was seen by the internal medicine consult
    team. He was found to be mildly sedated from pain
    medicines but would answer questions. He had mild
    pain from incision site, but otherwise had no
    tremors, nausea, diaphoresis, or signs of
    anxiety/agitation. He had no visual or auditory
    hallucinations. Physical exam was benign.

Case Presentation
  • The CIWA-Ar score was used in assessing the
    patient, and he was found to have a CIWA-Ar of 0.
    The urology team was notified of findings and a
    copy of the CIWA-Ar scale was applied to his

  • ETOH withdrawal is a common problem facing
  • Has a wide range of presentations
  • DTs, being the most severe form must be treated
    as a medical emergency with monitoring, frequent
    pt. assessment, and both pharmacological and
    non-pharmacological strategies

  • Clinical assessment tools, such as the CIWA-Ar
    are useful and should be considered when
    assessing pts who ETOH withdrawal is suspected
    in, to help guide medication administration.
  • Clinical guidelines exist for medical treatment
    of withdrawal and should be followed