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ALCOHOL WITHDRAWAL SYNDROME

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Medical conditions ie Diabetes, Epilepsy ... Regular Medical checkups required. Alcohol Withdrawal Syndrome. IF EVER IN DOUBT CONTACT ... – PowerPoint PPT presentation

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Title: ALCOHOL WITHDRAWAL SYNDROME


1
ALCOHOL WITHDRAWAL SYNDROME
  • UNLOCKING THE MYTHS

Graham Fary Alcohol Other Drug Withdrawal
Nurse Maryborough Community Health Centre
Victoria Austrlia
2
Alcohol Withdrawal Syndrome
  • Is Usually Benign
  • Occasionally Serious
  • Lasts between 7 10 days

3
Alcohol Withdrawal SyndromeMechanism
  • Alcohol activates the GABA system in the brain
  • Amino acid system of rapid nerve transmission
  • Leads to inhibition of activity within the CNS
  • Hyperpolarises the cell membranes
  • Catecholamine system (adrenaline/nor adrenaline)
    inhibited
  • With chronic use, both the GABA and Catecholamine
    systems become less responsive
  • When alcohol is withdrawn there is no longer the
    inhibiting influences on the CNS
  • Takes 2 4 days for these systems to return to
    normal
  • During this time there is over activity of the
    catecolamine system leading to the manifestation
    of the Alcohol Withdrawal Syndrome
  • Occurs after cessation or significant reduction
    of prolonged alcohol use
  • Daily intake of 80 grammes or more (8 standard
    drinks) places a person at risk of developing
    Alcohol Withdrawal Syndrome

4
Minor Withdrawal Syndrome
  • Vast majority who withdraw experience only minor
    withdrawal syndrome
  • Resolves in 2 3 days
  • Tremor
  • Perspiration
  • Restlessness
  • Hypersensitivity to stimulation
  • Increased T. P. R. BP
  • Nausea, vomiting diarrhoea
  • Anxiety agitation
  • Nightmares
  • Insomnia
  • Dysphoria

5
Severe Withdrawal Syndrome
  • In a minority of patients complications can occur
    which results in severe withdrawal syndrome
  • Seizures
  • Disorientation, Confusion, Delirium Tremens
  • Hallucinosis

6
Severe Withdrawal SyndromeSEIZURES
  • Occur in about 5 of people withdrawing from
    significant amounts of alcohol
  • Occur early, predominantly in the first 24 48
    hours
  • Are Clonic/Tonic in type
  • Usually one off and time limited
  • Treat as per local protocols

7
Severe Withdrawal SyndromeDelirium Tremens
  • Infrequent, thought to be around 1-2 of people
    withdrawing from significant amounts of alcohol
  • Generally preventable if patient is adequately
    assessed, monitored and treated
  • Untreated DTs has a high mortality rate (around
    20) but is almost 100 avoidable
  • Hard to pick the AT RISK patient. However
    patients demonstrating significant withdrawal
    symptoms around gt0.15 are good candidates.
  • Typically arise 2 5 days after cessation of
    drinking
  • Is thought to be due to an overactive
    catecholamine system which goes beyond a certain
    threshold
  • This can be part of life threatening autonomic
    disturbance, Fluid balance and electrolyte
    disturbance, Hyperthermia, Vivid hallucinations
    and delirium.
  • The hallucinations in this context are usually
    visual (classically small, colourful and animals)
    and tactile
  • This group of patients usually require
    substantial doses of Diazepam to control their
    symptoms. WARNING these pts also tend to have
    significant liver disease and may need
    modification of their Diazepam to Oxazepam which
    doesnt rely on the liver so much for its
    elimination.

8
Severe Withdrawal SyndromeAlcoholic Hallucinosis
  • Uncommon though not rare
  • Hallucinations which are auditory in content in
    the context of no delirium or evidence of
    psychiatric problems
  • Patients are generally not too distressed as they
    are aware why they are experiencing them and that
    they will pass

9
Severe Withdrawal SyndromePredictors
  • Past Hx of severe withdrawal
  • Duration, amount and tolerance to large doses of
    alcohol In general the longer, more frequent,
    more regular intake in greater amounts
    increased likelyhood of severe withdrawal (there
    is not a direct linear relationship with
    severity)
  • Presence of concomitant illness, injury or recent
    surgery
  • Use of other Psychotropic drugs

10
Alcohol Withdrawal Key determinants to Treatment
  • Amount, duration and tolerance to alcohol or
    Concurrent drug therapy especially
    Benzodiazepines
  • PHx of Severe withdrawal syndrome
  • Medical conditions ie Diabetes, Epilepsy
  • Psychiatric problems inc. PHx of attempted
    suicide or suicide ideation
  • Suitability of home environment ie significant
    others support

11
Alcohol Withdrawal Syndrome Determinants to
treatment
  • Home based treatment-
  • - If no risk of severe withdrawal and there
    are no other adverse key determinants
  • Non medical Residential Care-
  • - If home not supportive but no medical
    intervention is needed, then a non medical
    residential care facility is appropriate

12
Alcohol Withdrawal Syndrome Determinants to
treatment
  • Where there is a need for medical intervention or
    the likelihood of severe withdrawal syndrome
    occurring, a medical residential unit/hospital is
    appropriate

13
Alcohol Withdrawal SyndromeGeneral Nursing Care
  • Where Possible
  • Limit external stimuli Noise, visitors, other
    pts especially if distressed
  • At night light on if possible to limit
    potential for disorientation
  • Regular orientation to day, date , time, place
  • Explanation of symptoms to reassure pt
  • If risk of injury may need to be nursed with
    mattress on the floor
  • Keep patient secure especially when severe
    symptoms are experienced

14
Withdrawal Scales
  • An Alcohol Withdrawal Scale should be used
  • Used to measure patients condition
  • Used to measure trends
  • High Scores are Predictors of development of
    delirium
  • Seizures are only predicitive in patients who
    have a Past Hx of them
  • Scores on-
  • Perspiration
  • Tremors
  • Anxiety
  • Agitation
  • Nausea Vomiting
  • Hallucinations
  • Orientation
  • Headaches
  • Facial Flushing
  • Seizures

15
Scoring of Alcohol Withdrawal Signs
16
Alcohol Withdrawal ScaleScores
  • Score lt 5 Mild Withdrawal Severity
  • Score 5 14 Moderate Withdrawal Severity
  • Score gt 15 Severe Withdrawal Severity
  • NB Rate of change between readings, look for
    trends

17
Alcohol Withdrawal ScaleIn Hospital
18
Alcohol Withdrawal SyndromePharmocotherapy
  • Benzodiazepine - Diazepam
  • Thiamine
  • Magnesium
  • Haloperidol

19
Alcohol Withdrawal SyndromeBenzodiazepines
  • Diazepam is generally the only BZD used due to
    its cross tolerance with alcohol which allows the
    withdrawal symptoms to be wiped out.
  • If loading dose used then 20mg every 1 2 hours
    for three to four doses (i.e. 60 80 mgs) for
    first 24 48 hrs MAXIMUM daily dose of 120 mgs
    is generally advocated. (Alcohol dependent
    patients usually have higher doses due to cross
    tolerance)
  • No further dosing is required to treat
    withdrawal, but occasionally diazepam is given in
    accordance to the AWS and can be continued for a
    few days to manage pts anxiety
  • Dose Tapering is generally not recommended unless
    concurrently Benzodiazepine dependent Consult AD
    Specialist

20
Alcohol Withdrawal SyndromeThiamine
  • Thiamine should always be given - Alcohol reduces
    the bowels capacity to absorb Vitaman B1. It
    takes the bowel some days to weeks post
    withdrawal to resume its capacity to absorb B1
  • Has shown to reduce incidence of Wernickes
    Korsakoffs syndrome
  • Dose 50 100 mgs Daily I.M. for at least 3 days

21
Alcohol Withdrawal SyndromeMagnesium
  • Still controversial if to give routinely
  • Consider in cases of more severe withdrawal
  • If Low Serum Magnesium on presenting to hospital
    - appears to be increased risk for Severe
    Withdrawal Syndrome (i.e Delirium Tremens)

22
Alcohol Withdrawal SyndromeHaloperidol
  • Used where hallucinations and agitation are
    present and distressing despite repeated Diazepam
    dosing
  • Small doses 2 5 mgs Orally
  • Phenothiazines avoided as they can lower seizure
    threshold

23
Alcohol Withdrawal Syndrome
  • REMEMBER
  • Multidisciplinary approach, G.P. AD Specialist
    A D Nurse, AD Counsellor, Welfare, District
    Nurse, Social Worker, EMS etc all SHOULD be
    involved
  • Withdrawal small part not an end but a start to
    improving the patients life and changes
  • Withdrawal DOES NOT deal with the drug problem IT
    IS NOT A CURE it allows assessment of the
    patients situation in the best intellectual
    situation for that patient
  • Ongoing counselling and life changes required
  • Regular Medical checkups required

24
Alcohol Withdrawal Syndrome
  • IF EVER IN DOUBT CONTACT
  • Your Local
  • Alcohol Drug Specialist for advice

25
References
  • Dr Rodger Brough, Director, Western Region
    Alcohol Drug Withdrawal Service, Warrnambool,
    Victoria, Australia
  • Detoxification from Alcohol, Dr Tony Gill, GP
    Drug Alcohol Supplement No.7, Central Coast
    Area Health Service NSW, Australia, May 1997.
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