alcohol withdrawal Flashcards
sx of alcohol withdrawal
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.
RF of alcohol withdrawal
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
aetiology of alcohol withdrawal
abstinence from alcohol in a person with alcohol dependence.
pathology of alcohol withdrawal
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
epidemiology of alcohol withdrawal
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.
signs of alcohol withdrawal
- 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
sx of alcohol withdrawal
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
features of chronic or decompensated liver disease due to alcohol-use disorder
hepatomegaly
jaundice
ascites
caput medusa
palmar erythema
hepatic encephalopathy
features of poor nutrition
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.
scute intercurrent illnesses associated with alcohol withdrawal
pneumonia, pancreatitis, hepatitis, gastritis
signs suggestive of chronic alcohol missuse
Dupuytren’s contracture,
palmar erythema,bruising,
spider naevi,
telangiectasia,
facial mooning,
bilateral parotid enlargement,
gynaecomastia,
smell of alcohol.
kindling phenomena in alcohol withdrawal
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
stages in alcohol withdrawal and timeframe
minor withdrawal - 6-36hours
alcoholic hallucinosis - 12-48hr
withdrawal seizure - 6-48hrs
delerium tremens - 48-96hrs
sx of minor withdrawal
- tremor
- insomnia
- anxiety
- palpitations
- sweating
- GI upset
- headache
- lasts 24-48hrs
sx of alcoholic hallucinosis
consciousness intact - normal mental status
normal vital signs
auditory and/or visual hallucinations - tactile hallucinations
delusions
alcohol withdrawal seizures
brief
generalised tonic-clonic seizure - usually single episode
delirium tremens
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
sx of altered mental status in delerium tremens
impaired consciousness and disorientation
visual and tactile hallucinatiosn - small moving objects eg mice, crawling insects
increased suggestibility
sx of autonomic instability in delerium tremens
tachycardia
HTN
anxiety
nausea
sweating
fever
sx of neurological impairment in delerium tremens
psychomotor agitation - fidgiting, restlessness, tearfulness
generalised tonic-clonic seizures
insomnia
rest and intention tremor - 1st high freq then low
hyperreflexia
Ix of alcohol withdrawal
- 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
venous blood gas in alcohol withdrawal
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
blood glucose with alcohol withdrawal
hypoglycaemia secondary to poor nutrition or heavy alcohol use.
give glucose
FBC with alcohol withdrawal
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)
UE in alcohol withdrawal
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.
LFTs with alcohol withdrawal
elevated liver enzymes
AST, ALT, GGT - raised transaminases
bone profile in alcoholic withdrawal syndrome
hypocalcaemia - Secondary to hypomagnesaemia suppressing parathyroid hormone
low vit D
coagulation studies with alcohol withdrawal
prolonged INR and PT in chronic liver disease
CAGE questionnare
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)?
Mx of alcohol withdrawal
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
RF of delerium tremens
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.
Px of delerium tremens
mortality rate can be up to 35% if untreated but is less than 2% with early recognition and treatment
spectrum of alcohol withdrawal
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
