Alcohol Withdrawal

Question 1

define alcohol withdrawal?

Answer 1

symptoms that may occur when a person has been drinking too much alcohol on a regular basis

starts 10-72 hours after last drink

Question 2

explain the aetiology/risk factors of alcohol withdrawal?

Answer 2

chronic alcohol consumption suppresses the activity of glutamate ( An excitatory neurotransmitter)-> body compensates by increasing sensitivity to glutamate ( upregulate NMDA-R)

when alcohol consumption stops-> you get increased glutamate activity leading to excitatory symptoms

Question 3

summarise the epidemiology of alcohol withdrawal?

Answer 3

if untreated-> 6% of acohol dependent patients develop clinically relevant symptoms of withdrawal

up to 10 % of of them will delirium tremens

Question 4

what is a delirium tremens?

Answer 4

an acute confusional state -> see as withdrawal syndrome in chronic alcoholic and caused by sudden cessation of drinking alcohol

it can be precipitated by a head injury or an acute infection, causing absistence from alcohol

Question 5

what are the presenting symptoms and signs of alcohol withdrawal?

Answer 5

• History of high alcohol intake 
• Mild Symptoms:
○ Insomnia and fatigue 
○ Tremor 
○ Mild anxiety/feeling nervous 
○ Mild restlessness/agitation 
○ Nausea and vomiting 
○ Headache 
○ Sweating  
○ Palpitations 
increase pulse and decreased BP 
○ Anorexia 
○ Depression 
○ Craving alcohol

• More severe symptoms:
○ Hallucinations
○ Withdrawal seizures (generalised tonic-clonic)
Delirium tremens

Question 6

what are the features of delirium tremens?

Answer 6

anxiety 
tremor
sweating 
vivid and terrifying visual and sensory hallucinations ( usually of animals and insects 
can be fatal

Question 7

what are the appropriate investigations for alcohol withdrawal?

Answer 7

bloods

U and Es- elevated or normal ( dependent or

LFTs- to see if there are additional diagnosis like alcoholic hepatitis

Ethanol

Question 8

what are the appropriate investigations for alcohol withdrawal?

Answer 8

bloods

U and Es- elevated or normal ( dependent or

LFTs- to see if there are additional diagnosis like alcoholic hepatitis

Ethanol level

Question 9

outline a management plan for alcohol withdrawal?

Answer 9

• Chlordiazepoxide OR Diazepam OR Lorazepam - reduces symptoms of alcohol withdrawal
○ given as a high dose initially and then tailed off over 4–5 days
○ Dexmedetomidine may be prescribed as an adjunctant if management in ICU
○ If benzodiazepine-resistant then can give propofol

• Supportive care e.g. cardiac, maybe ICU care if admitted to hospital OR managing relapse by counselling
• Barbiturates may be used if refractory to benzodiazepines e.g. phenobarbitol
• Pabrinex sol – combo vitamin supplementation e.g. thiamine to prevent Wernicke’s encephalopathy or folic acid or magnesium sulphate

Glucose IV - Glucose should not be given before thiamine supplementation (unless critical hypoglycaemia) as this can precipitate Wernicke’s encephalopathy

Question 10

what are the possible complications of alcohol withdrawal?

Answer 10

patient can have seizures and die if it is left untreated

Question 11

summarise the presentation of alcohol withdrawal?

Answer 11

agitation 6 hours

hallucinations 12 hours

seizures 36 hours

delirium tremens 48 houra

Question 12

summarise the investigations for alcohol withdrawal?

Answer 12

The Clinical Institute Withdrawal Assessment for Alcohol–Revised (CIWA-Ar) to assess severity

FBC/ U and E/ LFT, INR , glucose

Question 13

summarise the management for alcohol withdrawal?

Answer 13

Benzodiazepines

Pabrinex ( B vitamin)

glucose