Prepared by J' Mabbutt

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7 Managing Alcohol Withdrawal
Prepared by J. Mabbutt C. MaynardNaMO September
2008
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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

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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

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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

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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

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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

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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

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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

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Figure 9.1 Progress of alcohol withdrawal
syndrome
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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?

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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

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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?

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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

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Table 9.4 Main signs symptoms of alcohol
withdrawal
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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

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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

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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)

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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