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March 2016 ALCOHOL WITHDRAWAL March 2016 ALCOHOL WITHDRAWAL

March 2016 ALCOHOL WITHDRAWAL - PowerPoint Presentation

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March 2016 ALCOHOL WITHDRAWAL - PPT Presentation

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

withdrawal alcohol patients treatment alcohol withdrawal treatment patients syndrome management amp severe dependence diagnosis seizures medical assessment symptoms hours

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Slide1

March 2016

ALCOHOL WITHDRAWAL

Slide2

Recognition of alcohol withdrawal symptomsEnsuring appropriate treatment so that complications are prevented

Describing the principles of detoxificationLEARNING POINTS

Slide3

Alcohol 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

Slide4

AnxietyTremorTachycardia

HypertensionAgitationAnorexia and nauseaHyper-reflexiaInsomnia Nightmares

SweatingHyperthermiaDisorientationSeizuresHallucinationsDelirium SIGNS AND SYMPTOMS

Slide5

Patients need to exhibit 2 of the following symptomsIncreased hand tremor

InsomniaNausea and vomitingTransient hallucinationsPsychomotor agitationAnxietyTonic-clonic seizuresAutonomic instability

DIAGNOSIS

Slide6

Patients 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

Slide7

Lack 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

Slide8

Symptoms 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

Slide9

Liver 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

Slide10

Inpatient 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

Slide11

Chlordiazepoxide 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

Slide12

PROTOCOL FOR TREATMENT Chlordiazepoxide/diazepam

Slide13

PROTOCOL FOR DIAZEPAM (please insert table)

Slide14

A 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

Slide15

Most 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

Slide16

Peak 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

Slide17

Thiamine 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

Slide18

Peripheral 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

Slide19

Patients 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

Slide20

Bayard, 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

disorders

BMJ

2015;350:h715

Mj

2015;350:h715 Doi:10.1136/bmj.h715

 

Drummond C, Ghodse H, &

Chengappa

S. (2007).

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

Slide21

Findings

(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;

vol

349, June 28

 

Hughes, J.R 2009).

"Alcohol withdrawal seizures"

.

Epilepsy

Behav

15

(2): 92–7

Muncie HL, Jr;

Yasinian

, Y;

Oge

', L (2013). "Outpatient management of alcohol withdrawal syndrome. American family physician

88

(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