Alcohol withdrawal

Question 1

What is alcohol withdrawal?

Answer 1

Alcohol withdrawal occurs in patients who are alcohol dependent and who have stopped or reduced their alcohol intake within hours or days of presentation.

Question 2

What are signs and symptoms of alcohol withdrawl?

Answer 2

Tremor, confusion, hallucinations, seizures

Tachycardia, hypotension, anxiety, sweating, palpitations

Question 3

What is the timeframe for alcohol withdrawl to occur?

Answer 3

Symptoms typically begin 6 to 12 (but up to 72) hours after the patient’s last alcoholic drink

Should be considered in any patients with acute confusion lasting < 3 days

Question 4

What are differential diagnoses for alcohol withdrawl?

Answer 4

• Delirium
	• Encephalopathy
	• Meningitis 
	• Traumatic brain injury - especially if symptoms atypical or prolonged (≥5 days since last alcohol).
	• Intoxication 
	• Hypoglycaemia 
Opioid withdrawal

Question 5

What Ix in acute alcohol withdrawl?

Answer 5

FAST score: screen for alcohol misuse

CAGE score: assess dependence

GMAWS

Bloods: glucose, alcohol, rule out infection

CT head: rule out TBI

Question 6

What is Rx for alcohol withdrawl?

Answer 6

Diazepam or chlordiazepoxide for 7 days (fixed dose) if dependent drinking, previous seizures, no cormorbidites.

Symptom triggered e.g. lorazepam is used in everyone

Vitamins replacement (Mg is important)

Pabrinex (thiamine)

Some may need anti-psychotics

Question 7

What is Wernicke-Korsakoff syndrome?

Answer 7

Wernicke encephalopathy is caused by thiamine (vitamin B1) deficiency (an essential coenzyme). Need pabrinex.

Korsakoff syndrome is a late complication of untreated Wernicke’s, and is a type of alcohol related brain injury with main signs being confabulation and dementia.

Question 8

What are signs and symptoms of Wernicke’s?

Answer 8

• Confusion
  
  • Ataxia
  • Ophthalmoplegia
  • Nystagmus
  • Hypothermia/hypotension
  • Decreased consciousness

Question 9

What is treatment of Wernicke’s?

Answer 9

• Day 1-2: IV Pabrinex + Mg
  
  • Day 3-5: IM Pabrinex
  • Day 6 onwards: change to oral thiamine

Question 10

What features may indicate patient is at risk of Wernicke’s, if they don;t yet have symptoms? How should they be treated?

Answer 10

• Weight loss (MUST =1)
  
  • Poor diet or vomiting <5 days
  • ALD
  • Seizures
  • Age < 18 or > 65

Severe risk factors:

* MUST >2 severe weight loss
* Poor diet or vomiting > 5 days

Give patients with no risk factors oral thiamine and those with risk factors Pabrinex to prevent Wernicke’s