Alcohol withdrawal

Question 1

Define withdrawal

Answer 1

A group of symptoms experienced following the discontinuation of medication or substance use

Question 2

How does complicated withdrawal differ from simple withdrawal?

Answer 2

Complicated withdrawal if any of:

• Seizures
• Delirium
• Psychosis

Question 3

When should prophylaxis be considered for alcohol withdrawal?

Answer 3

• Hx of dependence
• Previous withdrawal syndromes
• Consumption of 10+ units/d for past 10/7
• Current withdrawal

Question 4

Outline the classification of alcohol withdrawal syndrome

Answer 4

• Uncomplicated alcohol withdrawal syndrome
• Alcohol withdrawal syndrome with seizures
• Delirium Tremens

Question 5

Outline the presentation of alcohol withdrawal over a 3 day period

Answer 5

• 6-12 hr: Symptoms appear
• 36 hr: Seizure
• 48-72 hr: Delirium Tremens

Question 6

Give five symptoms of uncomplicated alcohol withdrawal syndrome?

Answer 6

Mild

• HTN; tachycardia
• Anorexia
• Anxiety; emotional lability; irritability
• Diaphoresis (sweating); headaches; fine tremor
• Insomnia

Moderate: worsening mild symptoms

• Agitation
• Coarse tremor

Severe/DT: worsening moderate symptoms

• Generalised tonic-clonic seizures
• Confusion; delirium
• Auditory and visual hallucinations
• Hyperthermia subsequent to psychomotor agitation

Question 7

Describe the illness progression of uncomplicated alcohol withdrawal syndrome

Answer 7

• Onset 4-12hr after last drink
• Peaks at 48hr
• Lasts 2-5 days.

Question 8

What type of seizure may be associated with alcohol withdrawal syndrome?

Answer 8

Generalised tonic-clonic

• Impaired awareness
• Initial generalised tonic extension of extremities
  
  • Lasting a few seconds
• Subsequent clonic rhythmic movements

Question 9

How many hours after the last drink would seizures appear in alcohol withdrawal syndrome?

Answer 9

6-48hrs after last drink

Question 10

Name three predisposing factors for seizures during alcohol withdrawal

Answer 10

• Previous withdrawal seizures
• Idiopathic epilepsy
• Hx of head injury
• Repeated detox
• Hypokalaemia

Question 11

Define Delirium tremens

Answer 11

Medical emergency

Delirium secondary to alcohol withdrawal

Question 12

Describe the progression of delirium tremens

Answer 12

• Onset 1-7d after last drink
• Peak at 48-72hr

Question 13

Name two risk factors for delirium tremens

Answer 13

• Severe dependence
• Comorbid infection
• Pre-existing liver damage

Question 14

What are the symptoms of delirium tremens?

Answer 14

• Confusion
• Auditory and visual hallucinations
• Fever; tachycardia
• Coarse tremor

Question 15

What is the medical management of alcohol-related withdrawal symptoms?

Answer 15

Alcohol detoxification

Question 16

Name three indications for inpatient detox

Answer 16

• PMH of complicated withdrawal
• Current confusion or delirium
• Comorbid illness; substance misuse; suicide risk
• Wernicke-Korsakoff syndrome
• Severe NaV or malnutrition
• Lack of stable home environment

Question 17

What medication is used in a detox reducing regime?

Answer 17

Benzodiazepines:

• Chlordiazepoxide (outpt):
  
  • Less abuse potential
• Diazepam (inpt)
  
  • Faster acting
  • Can be dose titrated against effect
  • May be given parenterally
  • Preferred if PMH withdrawal seizures

Question 18

What is the unwanted side effect of benzodiazepines

How is this counteracted?

Answer 18

• Addictive
• Longterm use: secondary iatrogenic dependence

Reduced by prescribing for a rapidly reducing regime, which covers the period of maximum risk.