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Title: presentation-07-managing alcohol withdrawal Author: WGEDD Last modified by: Ken Haywood Created Date: 9/21/2005 11:52:54 PM Document presentation format – PowerPoint PPT presentation

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Title: presentation-07-managing alcohol withdrawal


1
7 Managing Alcohol Withdrawal
Prepared by J. Mabbutt C. MaynardNaMO September
2008
2
7 Managing withdrawalObjectives
  • 1. During the session nurses midwives will
    learn how to identify, assess manage a patient
    in alcohol withdrawal
  • 2. By the end of the session nurses midwives
    will have an understanding or use of the
    AWS/CIWAR-Ar withdrawal scales
  • 3. At the end the session, nurses midwives will
    have a basic understanding knowledge to safely
    effectively identify, monitor manage alcohol
    withdrawal

3
7 Managing withdrawal
  • Effective management of withdrawal in its early
    stages can reduce or prevent progression to
    complicated withdrawal
  • Complicated withdrawal may be life-threatening
    due to
  • Accidental injury, dehydration, electrolyte
    imbalance, seizures, delirium tremens, or the
    negative impact on other concurrent disorders,
    including acute infection, renal disease or
    diabetes

4
7 Indications and guidelines Assessing
withdrawal
  • Severe alcohol withdrawal is potentially life
    threatening
  • The most important thing is to anticipate when it
    may occur to suspect it when an unexplained
    acute organic brain syndrome is detected
  • Before continuing to assess alcohol withdrawal,
    the following information focuses on a form of
    brain injury called the Wenickes-Korsakoff
    syndrome

5
7 Indications and guidelines Complications of
misuse Wernicke-Korsakoff syndrome (1)
  • This is a form of brain injury resulting from
    thiamine deficiency, which complicates alcohol
    dependence
  • If not treated early it can lead to permanent
    brain damage memory loss young
    alcohol-dependent people are at risk
  • Signs symptoms of Wernickes encephalopathy,
    which is usually the first stage of the syndrome,
    are
  • Ophthalmoplegia (reduced eye movements or
    nystagmus)
  • Ataxia confusion

6
7 Indications and guidelines Complications of
misuse Wernicke-Korsakoff syndrome (2)
  • This condition is reversible if recognised and
    treated with parenteral vitamin B1
  • Parenteral thiamine should be administered before
    any form of glucose
  • Glucose in the presence of thiamine deficiency
    risks precipitating Wernickes encephalopathy

7
7 Indications and guidelines Assessing
withdrawal Onset duration of alcohol
withdrawal (1)
  • Onset of alcohol withdrawal is usually 6-24 hours
    after the last drink
  • Consumption of benzodiazepines or other sedatives
    may delay the onset of withdrawal
  • In some severely dependent drinkers, simply
    reducing the level of consumption may precipitate
    withdrawal, even if they have consumed alcohol
    recently

8
7 Indications and guidelines Assessing
withdrawal Onset duration of alcohol
withdrawal (2)
  • Usually withdrawal is brief resolves after 2-3
    days without treatment occasionally, withdrawal
    may continue for up to 10 days
  • Withdrawal can occur when the blood alcohol level
    is decreasing, even if the patient is still
    intoxicated

9
Figure 9.1 Progress of alcohol withdrawal
syndrome
10
7 Indications and guidelines Assessing
withdrawal Index for Suspicion of Alcohol
withdrawal (1)
  • Severity of alcohol withdrawal ranges from mild
    to severe
  • The following questions, known as the Index for
    Suspicion of Alcohol Withdrawal, will help you
    determine whether the patient is likely to move
    into alcohol withdrawal
  • A regular intake of 80 grams (8 drinks-Males) or
    60 grams (6 drinks-Females) of alcohol or more
    per day?
  • Taken even smaller amounts of alcohol in
    conjunction with other CNS depressants?
  • Previous episodes of alcohol withdrawal?

11
7 Indications and guidelines Assessing
withdrawal Index for Suspicion of Alcohol
withdrawal (2)
  • Current admission for an alcohol-related reason?
  • Physical appearance indicate chronic alcohol use
  • parotid swelling (swelling in the gland under the
    ear)
  • cushingoid face (full/moon looking face)
  • facial telangiectasia (red spots/blood vessels)
  • eyes reddened or signs of liver disease
  • ascites, jaundice, limb muscle wasting

12
7 Indications and guidelines Assessing
withdrawal Index for Suspicion of Alcohol
withdrawal (3)
  • Pathology results show raised serum GGT
  • Raised mean cell volume (MCV)
  • Displaying symptoms such as
  • anxiety,
  • agitation,
  • tremor,
  • sweatiness or early morning retching, which
    might be due to an alcohol withdrawal syndrome?

13
7 Indications and guidelines Signs symptoms
of alcohol withdrawal (1)
  • Alcohol withdrawal is a syndrome of central
    nervous system hyperactivity characterised by
    symptoms that range from mild to severe
  • The symptoms and signs of alcohol withdrawal may
    be grouped into three major classes See Table
    9.4

14
Autonomic overactivity Gastrointestinal Cognitive perceptual changes
Sweating Anorexia Anxiety
Tachycardia Nausea Vivid dreams
Hypertension Vomiting Illusions
Insomnia Dyspepsia Hallucinations
Tremor Delirium
Fever
Table 9.4 Main signs symptoms of alcohol
withdrawal
15
7 Indications and guidelines Signs symptoms
of alcohol withdrawal (2)
  • Seizures occur in about 5 of patients
    withdrawing from alcohol
  • They occur early (usually 7-24 hours after the
    last drink), are grand mal in type (i.e.
    generalised, not focal) usually (though not
    always) occur as a single episode
  • Delirium tremens (the DTs) is rare is a
    diagnosis by exclusion
  • It is the most severe form of alcohol withdrawal
    syndrome, a medical emergency

16
7 Indications and guidelines Signs symptoms
of alcohol withdrawal (3)
  • DTs usually develops 2-5 days after stopping or
    significantly reducing alcohol consumption
  • The usual course is 3 days, but can be up to 14
    days
  • Its clinical features are
  • Confusion disorientation
  • Extreme agitation or restlessness the patient
    often requires restraining

17
7 Indications and guidelines Signs symptoms
of alcohol withdrawal (4)
  • Gross tremor
  • Autonomic instability (e.g. fluctuations in BP
    pulse), disturbance of fluid balance
    electrolytes, hyperthermia
  • Paranoid ideation, typically of delusional
    intensity
  • Distractibility accentuated response to
    external stimuli
  • Hallucinations affecting any of the senses, but
    typically visual (highly coloured, animal form)

18
7 Indications and guidelinesAlcohol withdrawal
scales (1)
  • The most systematic useful way to measure the
    severity of withdrawal is to use a withdrawal
    scale
  • These provide a baseline against which changes in
    withdrawal severity may be measured over time
  • Research shows that the use of scales minimises
    both under-dosing overdosing with
    benzodiazepines for alcohol withdrawal syndromes

19
7 Indications and guidelinesAlcohol withdrawal
scales (2)
  • There has been considerable debate about the
    application of withdrawal scales
  • Two different scales, the Alcohol Withdrawal
    Scale (AWS) and the Clinical Institute Withdrawal
    Assessment for Alcohol (revised) (CIWA-Ar) are
    both are recommended for use (see Appendices 2
    and 3)
  • Being familiar with the alcohol withdrawal scale
    used in your local area is a priority

20
7 Indications and guidelinesAlcohol withdrawal
scales (3)
  • Note that withdrawal scales do not diagnose
    withdrawal, but are merely guides to the severity
    of an already diagnosed withdrawal syndrome
  • The nurse or midwife should re-evaluate the
    patient to ensure that it is alcohol withdrawal
    not another condition that is being measured,
    particularly if the patient does not respond well
    to treatment

21
7 Alcohol withdrawal scales Clinical Institute
Withdrawal Assessment for Alcohol Revised Version
(CIWA-Ar) (1)
  • The CIWA-Ar (see Appendix 2) is a 10-item scale
    that can be administered as part of supportive
    care
  • Several studies have shown that the CIWA-Ar scale
    is a valid, reliable sensitive instrument for
    assessing the clinical course of simple alcohol
    withdrawal

22
7 Alcohol withdrawal scales Clinical Institute
Withdrawal Assessment for Alcohol Revised Version
(CIWA-Ar) Videos
  • Video options show either of the following from
    the CIWA-Ar CD ROM
  • E5 Using the CIWA-Ar alcohol withdrawal scale
    (withdrawal symptoms are demonstrated) (10.37
    min)
  • E8 A Case study

23
7 Alcohol withdrawal scales Clinical Institute
Withdrawal Assessment for Alcohol Revised Version
(CIWA-Ar) (2)
  • This scale allows a quantitative rating (from 0
    to 7 with a maximum possible score of 67) of the
    following components of withdrawal
  • Nausea vomiting
  • Tremor
  • Paroxysmal sweats
  • Anxiety

24
7 Alcohol withdrawal scales Clinical Institute
Withdrawal Assessment for Alcohol Revised Version
(CIWA-Ar) (3)
  • Agitation
  • Tactile disturbances
  • Auditory disturbances
  • Visual disturbances
  • Headache and fullness in head
  • Orientation clouding of sensoria

25
7 Alcohol withdrawal scales Clinical Institute
Withdrawal Assessment for Alcohol Revised Version
(CIWA-Ar) (4)
  • Using the CIWA-Ar in presentation to the
    emergency department
  • Monitor the patient hourly for at least 4 hours
    using the CIWA-Ar
  • Contact the medical officer or drug alcohol
    nurse practitioner for assessment and monitor
    hourly if
  • the alcohol score increases by at least 5 points
    over this 4-hour period, or
  • the CIWA-Ar total score reaches 10

26
7 Alcohol withdrawal scales Clinical Institute
Withdrawal Assessment for Alcohol Revised Version
(CIWA-Ar) (5)
  • Using the CIWA-Ar for hospitalised patients
  • Monitor the patient 4-hourly, using the CIWA-AR,
    for at least 3 days
  • If the total score reaches 10, monitor hourly
    notify the medical officer or drug alcohol
    nurse practitioner

27
7 Alcohol withdrawal scales Alcohol withdrawal
scale (AWS) (1)
  • Alcohol Withdrawal Scale (AWS)
  • The AWS (see Appendix 3) is a widely used scale
    in NSW
  • If a patients history or presentation suggests
    possible withdrawal, the patients condition must
    be monitored documented

28
7 Alcohol withdrawal scales Alcohol withdrawal
scale (AWS) (2)
  • The AWS (see Appendix 3) is a widely used scale
    in NSW and is a 7 item scale that allows a
    quantitative rating (from 0 to 4) of the
    following components
  • Perspiration
  • Tremor
  • Anxiety
  • Agitation
  • Axilla temperature
  • Hallucinations
  • Orientation

29
7 Alcohol withdrawal scales Alcohol withdrawal
scale (AWS) (3)
  • Using the AWS in presentation to the emergency
    department
  • Monitor the patient hourly for at least 4 hours
    using the AWS
  • Contact the medical officer or drug alcohol
    nurse practitioner for assessment monitor
    hourly if
  • the alcohol score increases by at least 5 points
    over this 4-hour period, or
  • the AWS total score reaches 5

30
7 Alcohol withdrawal scales Alcohol withdrawal
scale (AWS) (4)
  • Using the AWS for hospitalised patients
  • Monitor the patient 4-hourly, using the AWS, for
    at least 3 days
  • If the total score reaches 5, monitor hourly
    notify the medical officer or drug alcohol
    nurse practitioner
  • Depending on the resources of the local area,
    these may need review

31
7 Indications and guidelinesPharmacological
Treatment (1)
  • From NSW Drug Alcohol Withdrawal Clinical
    Practice Guidelines NSW Health 2007
  • The most commonly prescribed pharmacological
    treatment for alcohol withdrawal is diazepam
    because of its cross-tolerance with alcohol
    anti-convulsant properties
  • Two types of regimes for specialist residential
    or inpatient setting
  • Diazepam loading regime
  • Symptom-triggered sedation

32
7 Indications and guidelinesPharmacological
Treatment (2)
  • Diazepam loading regime
  • On the development of withdrawal symptoms
    initiate diazepam loading
  • 20mg initially, increasing to 80mg over 4-6 hours
  • Or until pt is sedated
  • Medial review required if dose exceeds 80mg
    more diazepam can be ordered depending on
    withdrawal condition

33
7 Indications and guidelinesPharmacological
Treatment (3)
  • Symptom-triggered sedation
  • Mild withdrawal CIWA-AR lt10 AWS lt4
  • Supportive care, observations 4 hourly
  • If sedation necessary 5-10mg oral diazepam every
    6-8 hours for first 48 hrs

34
7 Indications and guidelinesPharmacological
Treatment (4)
  • Symptom-triggered sedation
  • Moderate withdrawal CIWA-AR 10-20 AWS lt5-14
  • Medical officer to assess
  • If alcohol withdrawal confirmed hourly
    observations give 10-20 oral diazepam
    immediately repeat 10mg hourly or 10-20mg 2hrly
    until the pt achieves good symptom control (up to
    a total dose of 80mg)
  • Repeat medical review after 80mg of diazepam and
    if pt is not settling, consider olanzepine
    (zyprexia) 5-10mg

35
7 Indications and guidelinesPharmacological
Treatment (5)
  • Symptom-triggered sedation
  • Severe withdrawal CIWA-AR 20 AWS 14
  • Urgent management. Give a loading dose
  • Review more frequently until score falls
  • A rising score indicates a need for more
    aggressive management

36
7 Indications and guidelinesPharmacological
Treatment (6)
  • Contraindications to diazepam include
  • respiratory failure,
  • significant liver impairment,
  • possible head injury or cerebrovascular accident
    in these situations, specialist consultation is
    essential
  • From NSW Drug and Alcohol Withdrawal Clinical
    Practice Guidelines NSW Health 2007
    http//www.health.nsw.gov.au/policies/gl/2008/GL20
    08_011.html
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