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Alcohol Withdrawal

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13-1. Alcohol Withdrawal. Delirium Tremens. J. Paul Seale, M.D. Professor ... History of DTs, W/D seizures, delirium, or psychosis ... – PowerPoint PPT presentation

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Title: Alcohol Withdrawal


1
Alcohol Withdrawal Delirium Tremens
  • J. Paul Seale, M.D.
  • Professor
  • Department of Family Medicine

2
Patients At-Risk for Alcohol Withdrawal
  • Patients consuming alcohol every day for 3 weeks
    for more

3
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?

4
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

5
Withdrawal is Treatable
  • Low-risk patients outpatient detox
  • High risk patients inpatient detox

6
Alcohol/Sedative Withdrawal
7
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.)

8
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

9
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
10
Management of Asymptomatic Patients
  • Schedule for re-evaluation in 24 hours
  • If still asymptomatic, encourage abstinence and
    AA
  • Follow up in 1-4 weeks

11
Treatment for Symptomatic Patients
  • Sedative-hypnotic replacement
  • Classes Benzodiazepines
  • Barbiturates
  • Carbamazepine (Europe)

12
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

13
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

14
Advantages of Benzodiazepine Loading
  • Tapering unnecessary
  • May give single dose of 10-20 mg for home use prn
    anxiety or insomnia

15
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

16
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

17
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

18
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

19
Treatment Alternatives
  • Chlordiazepoxide
  • Lorazepam
  • Oxazepam
  • Valproic acid
  • Clonidine
  • Carbamazepine
  • Chlormethiazole
  • Phenobarbital

20
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

21
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

22
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)

23
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)

24
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

25
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
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