Alcohol Withdrawal

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Alcohol Withdrawal Delirium Tremens

• J. Paul Seale, M.D.
• Professor
• Department of Family Medicine

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Patients At-Risk for Alcohol Withdrawal

• Patients consuming alcohol every day for 3 weeks
  for more

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Assessment of Withdrawal Risk

• History of previous treatment for alcohol
  withdrawal
• Ask the pt Do you get sick or shaky if you go 2
  or 3 days without drinking?
• When is the last time you went 2 or 3 days
  without drinking?

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Risk Factors for Severe Withdrawal

• Age gt 65
• More than 12 drinks per day
• History of DTs, W/D seizures, delirium, or
  psychosis
• Acute Med Problems head trauma, unstable liver
  fx, pneumonia, angina, severe COPD, unstable
  arrhythmia
• Concurrent drug dependence

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Withdrawal is Treatable

• Low-risk patients outpatient detox
• High risk patients inpatient detox

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Alcohol/Sedative Withdrawal
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Timing of Detox

• Goal Early treatment of initial symptoms and
  prevention of severe withdrawal
• Procedure for outpatient detox Ask patient to
  stop drinking at noon on the day prior to detox
  evaluation, then come in at 830 AM (Mon., Tues.,
  or Wed.)

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Assess for Signs and Symptoms of Alcohol
Withdrawal

• Tachycardia
• Increased systolic blood pressure
• Increased temperature (rule out infection)
• Diaphoresis
• Anxiety/fear
• Insomnia/nightmares
• Vomiting/diarrhea
• Tremor

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Nursing Assessment Tool CIWA (Clinical
Withdrawal Assessment Scale)

• Temperature
• Pulse
• Respiration
• Blood Pressure
• Anxiety
• Agitation
• Tremor

• Diaphoresis
• Eating disturbance
• GI distress nausea, vomiting, diarrhea
• Sleep disturbances
• Clouding of sensorium
• Hallucinations
• Convulsions

Score Stage 1 lt5 Stage 2 5-10 Stage 3 gt10
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Management of Asymptomatic Patients

• Schedule for re-evaluation in 24 hours
• If still asymptomatic, encourage abstinence and
  AA
• Follow up in 1-4 weeks

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Treatment for Symptomatic Patients

• Sedative-hypnotic replacement
• Classes Benzodiazepines
• Barbiturates
• Carbamazepine (Europe)

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Benzodiazepine Treatment for Alcohol and
Sedative Withdrawal

• Rationale
• Rapid induction
• Easy transition
• Adequate control of symptoms
• Prevention of Stage 2, 3 withdrawal
• Partially protective against seizures
• Side effects over-sedation, aspiration
  pneumonia, drug dependence

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FHC Outpatient Protocol for Symptomatic Patients

• Move Patient to Treatment Room
• Nurse does CIWA assessment
• Give 10-20 mg po Valium if sx present
• Repeat CIWA hourly
• Give 10-20 mg Valium q 1-2 hours until pt is
  sedated but arousable
• Sit up drink water prior to each dose (assesses
  aspiration risk)
• Observe for 1 hr after each dose

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Advantages of Benzodiazepine Loading

• Tapering unnecessary
• May give single dose of 10-20 mg for home use prn
  anxiety or insomnia

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Preferred Medication for Inpatient
Detoxification Lorazepam (Ativan)

• Renal excretion (no need to adjust dose even in
  liver failure)
• Short-acting (rapid reversal in cases of
  accidental oversedation)
• Available for IV or IM use

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Ativan Dosing

• Mild W/D 4 mg po/2mg IV loading dose, then 2 mg
  po or IV Q 1-2 hrs until sedated
• Moderate W/D 12 mg po/4mg IV loading dose, then
  4 mg po or 2 mg IV Q 1-2 hrs until sedated
• Severe W/D hallucinations, sweating, tremors,
  agitation notify MD, cardiac monitor, transfer
  to ICU, Ativan 2mg/minute until sedated or IV drip

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Key Concepts in Detox Treatment

• Early, aggressive treatment of mild withdrawal
• Careful monitoring
• Awareness of profound tolerance in some patients
  (dosage increases of 10 fold or more, e.g. Valium
  1000 mg/day)
• Kindling effect over time

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Key Concepts in Detox Treatment

• Beware concurrent medical problems (aspiration
  pneumonia, acute MI, congestive heart failure,
  COPD)
• Monitor fluid-electrolyte balance, including Ca
  and Mg

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Treatment Alternatives

• Chlordiazepoxide
• Lorazepam
• Oxazepam
• Valproic acid

• Clonidine
• Carbamazepine
• Chlormethiazole
• Phenobarbital

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Phenobarbital Protocol for Treatment of Sedative
Withdrawal

• Loading and Supplemental (sodium luminal)
• 130-160 mg. IM as needed
• Phenobarbital (routine) orally
• 30 mg. 4 times a day x 3 days
• 15 mg. 4 times a day x 2 days
• 15 mg. twice a day x 1 day

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Heavy Phenobarbital Protocol for Treatment of
Sedative Withdrawal

• Loading and Supplemental (sodium luminal)
• 240 mg. IM Q 2 hrs up to 3 doses
• Phenobarbital (routine) orally
• 120 mg 3 times a day x 2 days
• 90 mg 3 times a day x 2 days
• 60 mg 3 times a day x 2 days
• 30 mg 3 times a day x 2 days
• 15 mg 3 times a day x 2 days

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Carbamazepine

• Excellent for polysedative abuse
• Anticonvulsant, no resp depr, can use with Etoh
  or drugs on board
• Loading 100 mg Q4hr x 4 doses then
• 200 mg q 6 hrs until therapeutic
• Continue 10 days-8 wks (diazepam, alprazolam)

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IV Treatment of Severe DTs

• Ativan infusion (beware propylene glycol toxicity
  at high doses, leading to lactic acidosis)
• May add other IV agents
• Fentanyl
• Propofol (problems cardio-resp depression,
  bacterial contamination)

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Adjunctive Medications Used in Alcohol
Withdrawal

• Thiamine, folic acid, MVI
• Haldol 5-10 mg IM for hallucinations
• HTN atenolol 25 mg or clonidine 0.1 mg for HTN

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Adjunctive Medications Used in Alcohol
Withdrawal

• Nausea hydroxyzine 25 mg
• Anxiety buspirone or Paxil
• Depression SSRI
• Naltrexone 50 mg Qd or Acamprosate 666mg tid _at_
  d/c