Recognition of alcohol withdrawal symptoms Ensuring appropriate treatment so that complications are prevented Describing the principles of detoxification LEARNING POINTS Alcohol withdrawal syndrome AWS is a set of symptoms which occur when a person reduces or stops alcohol consumption after ch ID: 915975
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Slide1
March 2016
ALCOHOL WITHDRAWAL
Slide2Recognition of alcohol withdrawal symptomsEnsuring appropriate treatment so that complications are prevented
Describing the principles of detoxificationLEARNING POINTS
Slide3Alcohol withdrawal syndrome (AWS) is a set of symptoms which occur when a person reduces or stops alcohol consumption after chronic heavy drinking
AWS is a hyperexcitable response from the CNS to lack of alcoholPeriods of acute intoxication followed by acute detoxification affect the brain profoundly and lead to seizures and cognitive deficitsNeurotoxic effects lead to adverse effects AWS can occur in people dependent on alcohol, and in those who binge drink
CONTEXT
Slide4AnxietyTremorTachycardia
HypertensionAgitationAnorexia and nauseaHyper-reflexiaInsomnia Nightmares
SweatingHyperthermiaDisorientationSeizuresHallucinationsDelirium SIGNS AND SYMPTOMS
Slide5Patients need to exhibit 2 of the following symptomsIncreased hand tremor
InsomniaNausea and vomitingTransient hallucinationsPsychomotor agitationAnxietyTonic-clonic seizuresAutonomic instability
DIAGNOSIS
Slide6Patients may choose to cope with symptoms rather than be labelledFear of being found out
Problem not presented by patients or identified by health professionalLack of knowledge by practitioner making the assessment BARRIERS TO DETECTION OR ACCESS
Slide7Lack of money to purchase alcoholUndetected alcohol problem in police custody
Acute illness or injury preventing access to alcoholNausea or vomitingDecision to stop drinking without medical supervisionWHY DOES WITHDRAWAL TAKE PLACE
Slide8Symptoms and signs will start about 6-24 hours after last drinkThere is peak at about 48-72 hours
Severity can be mild to severe which are life threatening eg delirium, hallucinations, seizuresSeverity is related to factors eg extent of consumption, duration of use, previous history of alcohol withdrawalDifferential diagnoses are: alcoholic hallucinosis, withdrawal seizures, delirium tremens
High risk of withdrawal: high blood alcohol level, pyrexia, tachycardia, physical illness, concurrent use of benzodiazepines or other drugsASSESSMENT
Slide9Liver function tests:Gamma
glutamyl transferase GGTMagnesiumFull blood count (FBC)Mean cell volume (MCV)Clotting Thiamine deficiency
AUDIT Alcohol use disorders identification test & AUDIT – C FAST CAGEPAT SADQ – Severity of alcohol dependence questionnaireCIWA-Ar – Clinical Institute withdrawal assessment of Alcohol Scale INVESTIGATIONS AND TOOLS
Slide10Inpatient admission if patient has:Severe dependence
ComorbiditiesUnstable home Polydrug usersPrevious unsuccessful attempts at withdrawalIf mild dependence, with no medical complications and support at home, withdrawal can be supervised by a community alcohol team
TREATMENT OF ALCOHOL WITHDRAWAL
Slide11Chlordiazepoxide or diazepam is treatment of choice for moderate to severe dependence (assessed by SADQ and CIWA-
Ar scales)Treatment dose should be titrated to the scores on both scales Older and young people – cautiously use lower doses and monitor Psychosocial interventions should be administered once the patient is well enough to participate
TREATMENT – ALCOHOL WITHDRAWAL
Slide12PROTOCOL FOR TREATMENT Chlordiazepoxide/diazepam
Slide13PROTOCOL FOR DIAZEPAM (please insert table)
Slide14A medical emergencyThe most severe form of withdrawalOccurs in 5-20% patients experiencing detoxification
Occurs in 33% patients experiencing withdrawal seizuresIt can be fatal in 5% patients if not treated promptlyDELIRIUM TREMENS
Slide15Most serious complication of withdrawalFluctuating confusion, severe tremor, autonomic features, visual and auditory hallucinations
Peak onset 48-72 hours after withdrawal after cessation of drinkingTreatment includes chlordiazepoxide (see table) and may have to be administered parenterallyIM/IV pabrinex 2 pairs tds for 3-5 days
Haloperidol 0.5 – 5 mg prn for disturbed behaviour TREATMENT - DELIRIUM TREMENS
Slide16Peak at 48 hours post cessation of alcohol consumptionOccur in 1-15% of alcohol withdrawals
Treatment: increase dose of benzodiazepines and initiate or continue anti-convulsantsTREATMENT FOR ALCOHOL WITHDRAWAL SEIZURES
Slide17Thiamine B1 deficiency can cause Wernicke’s encephalopathy and Korsakoff’s Syndrome
Syndrome includes: Confusion, ataxia, ophthalmoplegiaKorsakoff’s: profound short term memory defectUntreated 20% mortalityPatients should be prescribed oral thiamine 200mg bd and vitamin Co Strong 2 tabs BD
Parenteral thiamine is given in hospital WERNICKE KORSAKOFF’S SYNDROMEVITAMIN DEFICIENCY TREATMENT
Slide18Peripheral neuropathyCardiovascular disorder: hypotension or high output cardiac failure
Mild peripheral or severe incapacitating sensor motor neuropathyFoot dropDistal muscle weakness or wastingOther forms of neuropathy eg vascular, viral, trauma, carcinomaOTHER NEUROLOGICAL NUTRITIONAL DEFICIENCIES
Slide19Patients need a lot of support after detoxification which is the start not the end of treatmentPatients need assistance to make links and appointments with agencies
Specialist agencies eg addiction servicesSelf help groups can be very helpful: Alcoholic anonymous, Al-Anon and Ala-teen REFERRAL NETWORKS
Slide20Bayard, M, McIntyre J, & Hill KR, Woodside J (2004).
"Alcohol withdrawal syndrome"
. American Family Physician 69
(6): 1443–50.Brathen G.E. et al (2005) EFNS guideline on diagnosis and management of alcohol related seizures: report of an EFNS task force. European Journal of Neurology,12 (8): 575-581
Crome, I. B & Bloor, R (2008) Alcohol problems, in Essential Psychiatry, Ed Robin Murray, Cambridge University Press.
Day, E,
Copello
A, Hull M (2015) Assessment and management of alcohol use
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Drummond C, Ghodse H, &
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Use of investigations in the diagnosis and management of alcohol use disorders.
In Clinical Topics in Addiction ed. E Day. London: Royal College of Psychiatrists.
Edwards G, Marshall J, Cook C.(2003). The treatment of drinking problems :a guide for the helping professions 4th ed. Cambridge: Cambridge University Press
References
Slide21Findings
(2013) Alcohol Matrix cell A3: Interventions; Medical treatment
http://findings.org.uk/count/downloads/download.php?file=Matrix/Alcohol/A3.htm
Hall, W & Zador
D (1997) The alcohol withdrawal syndrome, The Lancet;
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349, June 28
Hughes, J.R 2009).
"Alcohol withdrawal seizures"
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Epilepsy
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(2): 92–7
Muncie HL, Jr;
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, Y;
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', L (2013). "Outpatient management of alcohol withdrawal syndrome. American family physician
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(9): 589–95.
NICE (2011) Alcohol use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence (NICE clinical guideline, CG115)
http://guidance.nice.org.uk/CG115
Sech
G, & Serra A. (2007) Wernicke’s encephalopathy: new clinical settings and recent advances in diagnosis management: The Lancet Neurology, 6(5) 442-455.
References