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Yr 3 Acute Care and Trauma > alcohol withdrawal > Flashcards

alcohol withdrawal Flashcards

1
Q

sx of alcohol withdrawal

A

Caused by a sudden reduction or cessation of alcohol intake after a prolonged period of heavy drinking

Symptoms typically begin 6 to 12 hours after the patient’s last alcoholic drink, and may progress to life-threatening delirium tremens, with or without seizures.

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2
Q

RF of alcohol withdrawal

A

history of alcohol withdrawal syndrome and delirium tremens

Kindling – if you previously had the effects, seizures or delirium tremens – more likely to get the second time round

abrupt withdrawal of alcohol

heavy alcohol intake

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3
Q

aetiology of alcohol withdrawal

A

abstinence from alcohol in a person with alcohol dependence.

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4
Q

pathology of alcohol withdrawal

A

signs of overactivity of the sympathetic nervous system

Chronic alcohol use results in up-regulation of post-synaptic NMDAreceptors because EtOH competitively binds and inhibits, anddown-regulationof post-synapticGABA receptors because of overstimulation

chronic alcohol = increased release and reduced uptake of glutamate

A decrease in blood ethanol concentration = imbalance between stimulatory (NMDA) and inhibitory (GABA) systems in the central nervous system.

Excessive stimulatory effect with cessation = clinical signs and symptoms of alcohol withdrawal syndrome

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5
Q

epidemiology of alcohol withdrawal

A

43% of the world population consumes alcohol, with 18.2% of drinkers aged over 15 years engaging in heavy episodic alcohol consumption

In 2016, global prevalence of alcohol-use disorders (harmful use or dependance) was 5.1% among drinkers aged over 15 years.

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6
Q

signs of alcohol withdrawal

A
  • increased pulse
  • reduced BP
  • confusion
  • agitation
  • altered cognition
  • fits - generalised tonic-clonic - need urgent treatment
  • hallucinations (delerium tremens) - may be visual or tactile eg animals crawling all over the skin
  • features of chronic or decompensated liver disease due to alcohol-use disorder
  • poor nutrition
  • associated acute intercurrent illness
  • Deranged temperature or deranged blood pressure or deranged blood glucose, alongside any feature or alcohol withdrawal
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7
Q

sx of alcohol withdrawal

A

anxiety

nausea/vom

autonomic dysfunction

insomnia

craving for alcohol

headache

anorexia

depression

these symptoms may progress to severe withdrawal with seizures, psychiatric disturbance and delirium tremens

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8
Q

features of chronic or decompensated liver disease due to alcohol-use disorder

A

hepatomegaly

jaundice

ascites

caput medusa

palmar erythema

hepatic encephalopathy

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9
Q

features of poor nutrition

A

thiamine deficiency - Wernicke’s encephalopathy: nystagmus, ataxia, confusion

vit D def: RF: poor diet intake, lack sun, direct effect alcohol on vit d metabolism, Decreased absorption in patients with alcohol-related steatorrhoea.

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10
Q

scute intercurrent illnesses associated with alcohol withdrawal

A

pneumonia, pancreatitis, hepatitis, gastritis

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11
Q

signs suggestive of chronic alcohol missuse

A

Dupuytren’s contracture,

palmar erythema,bruising,

spider naevi,

telangiectasia,

facial mooning,

bilateral parotid enlargement,

gynaecomastia,

smell of alcohol.

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12
Q

kindling phenomena in alcohol withdrawal

A

multiple episodes of AWS increase severity of subsequent AWS

low chemical or electrical stimulus that doesnt normally produce an behavioural response = seizure from repetitive adminsitration

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13
Q

stages in alcohol withdrawal and timeframe

A

minor withdrawal - 6-36hours

alcoholic hallucinosis - 12-48hr

withdrawal seizure - 6-48hrs

delerium tremens - 48-96hrs

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14
Q

sx of minor withdrawal

A
  • tremor
  • insomnia
  • anxiety
  • palpitations
  • sweating
  • GI upset
  • headache
  • lasts 24-48hrs
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15
Q

sx of alcoholic hallucinosis

A

consciousness intact - normal mental status

normal vital signs

auditory and/or visual hallucinations - tactile hallucinations

delusions

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16
Q

alcohol withdrawal seizures

A

brief

generalised tonic-clonic seizure - usually single episode

17
Q

delirium tremens

A

rapid onset, difficult to control

sympathetic hyperactivity

profound confusion/delerium - fluctuating in nature and the patient may be disorientated to time, person, and place.

persistent clouding of consciousness

lasts 1-5 days

Visual, auditory, and tactile hallucinations; characteristically frightening delusions

‘pins and needles’, burning, and numbness.

coarse tremor

clinical instability - tachycardia, fever, ketoacidosis, and circulatory collapse

18
Q

sx of altered mental status in delerium tremens

A

impaired consciousness and disorientation

visual and tactile hallucinatiosn - small moving objects eg mice, crawling insects

increased suggestibility

19
Q

sx of autonomic instability in delerium tremens

A

tachycardia

HTN

anxiety

nausea

sweating

fever

20
Q

sx of neurological impairment in delerium tremens

A

psychomotor agitation - fidgiting, restlessness, tearfulness

generalised tonic-clonic seizures

insomnia

rest and intention tremor - 1st high freq then low

hyperreflexia

21
Q

Ix of alcohol withdrawal

A
  • VBG
  • blood glucose
  • FBC
  • UE
  • LFT
  • raised uric acid, TG or markers of end-organ damage eg BR, albumin, PT in liver
  • bone profile
  • coagulation studies
  • CAGE questionnaire
  • AUDIT questionnaire
  • severity of withdrawal - CIWA-Ar scale (Clinical Institute Withdrawal Assessment from Alcohol Revised scale
22
Q

venous blood gas in alcohol withdrawal

A

resp alkalosis when delirium tremens because elevated cardiac indices, ox delivery and ox consumption

hypervent and resp alkalosis with delerium tremens may = reduction in cerebral blood flow

hypochloraemic met acidosis with vomiting

met acidosis with a high anion gap if alcoholic ketoacidosis is present

23
Q

blood glucose with alcohol withdrawal

A

hypoglycaemia secondary to poor nutrition or heavy alcohol use.

give glucose

24
Q

FBC with alcohol withdrawal

A

increased MCV (indicative of chronic alcohol use disorder)

thrombocytopenia (splenomegaly, folate deficiency, and, most frequently, a direct toxic effect of alcohol on production, survival time, and function of platelets)

25
Q

UE in alcohol withdrawal

A

hypomg

hypokalaemia - inadequate intake and gastrointestinal losses due to diarrhoea. Urinary losses

hypophosphtaemia

may be normal or only slightly reduced on admission - decrease over several days. because inward cellular shift that unmasks decreased total-body stores.

26
Q

LFTs with alcohol withdrawal

A

elevated liver enzymes

AST, ALT, GGT - raised transaminases

27
Q

bone profile in alcoholic withdrawal syndrome

A

hypocalcaemia - Secondary to hypomagnesaemia suppressing parathyroid hormone

low vit D

28
Q

coagulation studies with alcohol withdrawal

A

prolonged INR and PT in chronic liver disease

29
Q

CAGE questionnare

A

have you ever felt you should cut down alcohol

Have people Annoyed you by criticising your drinking?

Have you ever felt bad or Guilty about your drinking?

Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (Eye opener)?

30
Q

Mx of alcohol withdrawal

A

shouldnt be inpatient detox as sole purpose of admission

only admit if there are complicating or co-existing medical problems that need treatment

check BP and TPR/4hr - beware low BP

benzodiazepines:

  • for 1st 3days chlordiazepoxide PO with additional doses PRN then sum total dose and plan weaning regimen over 5–7d. or diazepam
  • short acting - lorazepam - esp if liver disease

anticonvulsants eg carbamazepine if seizures continue

antipsychotics - haloperidol or risperidone if psychotic sx - never as independant med

thiamine - B1 deficiency prophylaxis or treatment

folate

multivitamies

IV fluid and electrolyte correction

dextrose

31
Q

RF of delerium tremens

A

Previous history of delirium tremens.

Previous history of alcohol withdrawal seizures.

Co-existing infection or medical problems including pancreatitis or hepatitis.

Recent higher-than-normal levels of alcohol intake.

Older age.

Abnormal liver function.

More severe withdrawal symptoms on presentation.

32
Q

Px of delerium tremens

A

mortality rate can be up to 35% if untreated but is less than 2% with early recognition and treatment

33
Q

spectrum of alcohol withdrawal

A

minor 6-24hr = anxiety, insomnia, tremor, N and v

Major 10-72hr

  • tremor,
  • autonomic signs - sweating, HTN
  • hallucinations - visual/auditory/tactile - formication (ants under skin)

seizures 6-48hr

  • multiple, brief generalised
  • 3% develop status epilepticus
  • >1/3 develop delerium tremens

<5% delerium tremens – total confusion and incoordination, psychosis

  • medical emergency - mortality 5-15% (arrhythmias)
  • agitation and delerium, intense fear
  • autonomic hyperactivity - HTN, high HR, temp and sweating

Yr 3 Acute Care and Trauma (6 decks)

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