Alcohol withdrawal

Question 1

Lorazepam to diazepam dosing

Answer 1

1mg of lorazepam is equivalent to around 8mg diazepam

Question 2

Alcohol withdrawal symptoms

Answer 2

• Anxiety/Agitation
• Nausea / Vomiting
• Sweating
• Tremor
• Fever (no infection)
• Hypertension
• Tachycardia
• Tachypnea
• Delerium Tremens*

Question 3

How can one assess a patient’s alcohol withdrawal symptoms

Answer 3

CIWA-Ar scoring system and physical observations (HR and BP)

Question 4

What is delirium tremens and how does it present?

Answer 4

• a rapid onset of confusion usually caused by withdrawal from alcohol
• Normally occurs 24-72 hours after alcohol withdrawal
• Symptoms include hallucinations, delirium, convulsions, severe agitation, and ataxia

Question 5

What is ataxia?

Answer 5

Ataxia is a loss of muscle control. People with ataxia lose muscle control in their arms and legs. This may lead to a lack of balance and coordination and trouble walking. Ataxia may affect the movements of:

Fingers

Hands

Arms

Legs

Body

Eyes

It can also affect the muscles that are used for speech.

Question 6

What to do if a patient with alcohol withdrawal starts having delirium tremens

Answer 6

Contact your senior immediately

Question 7

What does alcohol withdrawal treatment consist of?

Answer 7

A mixture of benzodiazepines and pabrinex or thiamine

Question 8

What is pabrinex?

Answer 8

A mixture of vitamin Bs and vitamin C

Question 9

Why is pabrinex or thiamine given?

Answer 9

Replenishes these vitamins as they are low in alcoholic patients which prevents the chances of them developing Wernicke’s encephalopathy or refeeding syndrome

Question 10

What is Wernicke’s encephalopathy?

Answer 10

An acute neurological condition characterized by a clinical triad of ophthalmoparesis with nystagmus, ataxia, and confusion

Question 11

What causes Wernicke’s encephalopathy?

Answer 11

A deficiency in thiamine (vitamin B1)

Question 12

What is ophthalmoparesis?

Answer 12

Weakness or paralysis of one or more extraocular muscles which are responsible for eye movements.

Question 13

Dosage of thiamine for alcohol withdrawal

Answer 13

• At risk of Wernicke;s -> 200mg IV OD (can be pushed to BD) 3-5 days, then oral thiamine 100mg BD
• Treatment of Wernicke’s –> 300mg IV TDS 3-5 days, if still symptomatic after 5 days then another 3-5 days 300mg IV once daily, then 100mg oral BD
• Further 3 months 100mg BD if a good diet can be achieved by patient, if not then 100mg BD indefinitely

Question 14

Benzodiazepine protocol fo alcohol withdrawal

Answer 14

Either symptoms triggered regimen or combined fixed and symptom triggered regimen
- In combined, a regular benzo dose is given based on usual alcohol intake, gradually reduced generally over 5 days, and a further PRN dose based on symptom withdrawal
- Symptoms triggered involves PRN Benzo dose based solely on withdrawal symptoms

Question 15

Signs/symptoms of Wernicke/s encephalopathy

Answer 15

• Ataxia
• Confusion
• 6th cranial nerve ophthalmoplegia affecting lateral rectus muscles (lateral nystagmus)
• Hypothermia and hypotension
• Memory disturbance