7: Managing
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7: Managing Alcohol Withdrawal. Prepared by J. Mabbutt & C. Maynard NaMO September 2008. 7: Managing withdrawal Objectives. 1. During the session nurses & midwives will learn how to identify, assess & manage a patient in alcohol withdrawal

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Prepared by j mabbutt c maynard namo september 2008

7: Managing

Alcohol Withdrawal

Prepared byJ. Mabbutt & C. MaynardNaMO

September 2008


Prepared by j mabbutt c maynard namo september 2008

7: Managing withdrawalObjectives

1. During the session nurses & midwives will learn how to identify, assess & manage a patient in alcohol withdrawal

2.By the end of the session nurses & midwives will have an understanding or use of the AWS/CIWAR-Ar withdrawal scales

3.At the end the session, nurses & midwives will have a basic understanding & knowledge to safely & effectively identify, monitor & manage alcohol withdrawal


Prepared by j mabbutt c maynard namo september 2008

7: Managing withdrawal

Effective management of withdrawal in its early stages can reduce or prevent progression to complicated withdrawal

Complicated withdrawal may be life-threatening due to:

Accidental injury, dehydration, electrolyte imbalance, seizures, delirium tremens, or the negative impact on other concurrent disorders, including acute infection, renal disease or diabetes


Prepared by j mabbutt c maynard namo september 2008

7: Indications and guidelines: Assessing withdrawal

  • Severe alcohol withdrawal is potentially life threatening

  • The most important thing is to anticipate when it may occur & to suspect it when an unexplained acute organic brain syndrome is detected

  • Before continuing to assess alcohol withdrawal, the following information focuses on a form of brain injury called the Wenicke’s-Korsakoff syndrome


Prepared by j mabbutt c maynard namo september 2008

7: Indications and guidelines: Complications of misuse – Wernicke-Korsakoff syndrome (1)

  • This is a form of brain injury resulting from thiamine deficiency, which complicates alcohol dependence

  • If not treated early it can lead to permanent brain damage & memory loss – young alcohol-dependent people are at risk

  • Signs & symptoms of Wernicke’s encephalopathy, which is usually the first stage of the syndrome, are:

  • Ophthalmoplegia (reduced eye movements or nystagmus)

  • Ataxia & confusion


Prepared by j mabbutt c maynard namo september 2008

7: Indications and guidelines: Complications of misuse – Wernicke-Korsakoff syndrome (2)

  • This condition is reversible if recognised and treated with parenteral vitamin B1

  • Parenteral thiamine should be administered before any form of glucose

  • Glucose in the presence of thiamine deficiency risks precipitating Wernicke’s encephalopathy


Prepared by j mabbutt c maynard namo september 2008

7: Indications and guidelines: Assessing withdrawal – Onset & duration of alcohol withdrawal (1)

  • Onset of alcohol withdrawal is usually 6-24 hours after the last drink

  • Consumption of benzodiazepines or other sedatives may delay the onset of withdrawal

  • In some severely dependent drinkers, simply reducing the level of consumption may precipitate withdrawal, even if they have consumed alcohol recently


Prepared by j mabbutt c maynard namo september 2008

7: Indications and guidelines: Assessing withdrawal – Onset & duration of alcohol withdrawal (2)

  • Usually withdrawal is brief & resolves after 2-3 days without treatment; occasionally, withdrawal may continue for up to 10 days

  • Withdrawal can occur when the blood alcohol level is decreasing, even if the patient is still intoxicated


Prepared by j mabbutt c maynard namo september 2008

Figure 9.1: Progress of alcohol withdrawal syndrome


Prepared by j mabbutt c maynard namo september 2008

7: Indications and guidelines: Assessing withdrawal – Index for Suspicion of Alcohol withdrawal (1)

  • Severity of alcohol withdrawal ranges from mild to severe

  • The following questions, known as the Index for Suspicion of Alcohol Withdrawal, will help you determine whether the patient is likely to move into alcohol withdrawal:

  • A regular intake of 80 grams (8 drinks-Males) or 60 grams (6 drinks-Females) of alcohol or more per day?

  • Taken even smaller amounts of alcohol in conjunction with other CNS depressants?

  • Previous episodes of alcohol withdrawal?


Prepared by j mabbutt c maynard namo september 2008

7: Indications and guidelines: Assessing withdrawal – Index for Suspicion of Alcohol withdrawal (2)

  • Current admission for an alcohol-related reason?

  • Physical appearance indicate chronic alcohol use:

    • parotid swelling (swelling in the gland under the ear)

    • cushingoid face (full/moon looking face)

    • facial telangiectasia (red spots/blood vessels)

    • eyes reddened or signs of liver disease

    • ascites, jaundice, limb muscle wasting


Prepared by j mabbutt c maynard namo september 2008

7: Indications and guidelines: Assessing withdrawal – Index for Suspicion of Alcohol withdrawal (3)

  • Pathology results show raised serum GGT

  • Raised mean cell volume (MCV)

  • Displaying symptoms such as

    • anxiety,

    • agitation,

    • tremor,

    • sweatiness or early morning retching, which might be due to an alcohol withdrawal syndrome?


Prepared by j mabbutt c maynard namo september 2008

7: Indications and guidelines: Signs & symptoms of alcohol withdrawal (1)

  • Alcohol withdrawal is a syndrome of central nervous system hyperactivity characterised by symptoms that range from mild to severe

  • The symptoms and signs of alcohol withdrawal may be grouped into three major classes: See Table 9.4


Prepared by j mabbutt c maynard namo september 2008

Table 9.4:Main signs & symptoms of alcohol withdrawal


Prepared by j mabbutt c maynard namo september 2008

7: Indications and guidelines: Signs & symptoms of alcohol withdrawal (2)

  • Seizures occur in about 5% of patients withdrawing from alcohol

  • They occur early (usually 7-24 hours after the last drink), are grand mal in type (i.e. generalised, not focal) & usually (though not always) occur as a single episode

  • Delirium tremens (“the DTs”) is rare & is a diagnosis by exclusion

  • It is the most severe form of alcohol withdrawal syndrome, & a medical emergency


Prepared by j mabbutt c maynard namo september 2008

7: Indications and guidelines: Signs & symptoms of alcohol withdrawal (3)

  • DT’s usually develops 2-5 days after stopping or significantly reducing alcohol consumption

  • The usual course is 3 days, but can be up to 14 days

  • Its clinical features are:

  • Confusion & disorientation

  • Extreme agitation or restlessness – the patient often requires restraining


Prepared by j mabbutt c maynard namo september 2008

7: Indications and guidelines: Signs & symptoms of alcohol withdrawal (4)

  • Gross tremor

  • Autonomic instability (e.g. fluctuations in BP & pulse), disturbance of fluid balance & electrolytes, hyperthermia

  • Paranoid ideation, typically of delusional intensity

  • Distractibility & accentuated response to external stimuli

  • Hallucinations affecting any of the senses, but typically visual (highly coloured, animal form)


Prepared by j mabbutt c maynard namo september 2008

7: Indications and guidelines:Alcohol withdrawal scales (1)

  • The most systematic & useful way to measure the severity of withdrawal is to use a withdrawal scale

  • These provide a baseline against which changes in withdrawal severity may be measured over time

  • Research shows that the use of scales minimises both under-dosing & overdosing with benzodiazepines for alcohol withdrawal syndromes


Prepared by j mabbutt c maynard namo september 2008

7: Indications and guidelines:Alcohol withdrawal scales (2)

  • There has been considerable debate about the application of withdrawal scales

  • Two different scales, the Alcohol Withdrawal Scale (AWS) and the Clinical Institute Withdrawal Assessment for Alcohol (revised) (CIWA-Ar) are both are recommended for use (see Appendices 2 and 3)

  • Being familiar with the alcohol withdrawal scale used in your local area is a priority


Prepared by j mabbutt c maynard namo september 2008

7: Indications and guidelines:Alcohol withdrawal scales (3)

  • Note that withdrawal scales do not diagnose withdrawal, but are merely guides to the severity of an already diagnosed withdrawal syndrome

  • The nurse or midwife should re-evaluate the patient to ensure that it is alcohol withdrawal & not another condition that is being measured, particularly if the patient does not respond well to treatment


Prepared by j mabbutt c maynard namo september 2008

7: Alcohol withdrawal scalesClinical Institute Withdrawal Assessment for Alcohol Revised Version (CIWA-Ar) (1)

  • The CIWA-Ar (see Appendix 2)is a 10-item scale that can be administered as part of supportive care

  • Several studies have shown that the CIWA-Ar scale is a valid, reliable & sensitive instrument for assessing the clinical course of simple alcohol withdrawal


Prepared by j mabbutt c maynard namo september 2008

7: Alcohol withdrawal scalesClinical Institute Withdrawal Assessment for Alcohol Revised Version (CIWA-Ar) – Videos

  • Video options show either of the following from the CIWA-Ar CD ROM

  • E5 Using the CIWA-Ar alcohol withdrawal scale (withdrawal symptoms are demonstrated) (10.37 min)

  • E8 – A Case study


Prepared by j mabbutt c maynard namo september 2008

7: Alcohol withdrawal scalesClinical Institute Withdrawal Assessment for Alcohol Revised Version (CIWA-Ar) (2)

  • This scale allows a quantitative rating (from 0 to 7 with a maximum possible score of 67) of the following components of withdrawal:

  • Nausea & vomiting

  • Tremor

  • Paroxysmal sweats

  • Anxiety


Prepared by j mabbutt c maynard namo september 2008

7: Alcohol withdrawal scalesClinical Institute Withdrawal Assessment for Alcohol Revised Version (CIWA-Ar) (3)

  • Agitation

  • Tactile disturbances

  • Auditory disturbances

  • Visual disturbances

  • Headache and fullness in head

  • Orientation & clouding of sensoria


Prepared by j mabbutt c maynard namo september 2008

7: Alcohol withdrawal scalesClinical Institute Withdrawal Assessment for Alcohol Revised Version (CIWA-Ar) (4)

Using the CIWA-Ar in presentation to the emergency department:

  • Monitor the patient hourly for at least 4 hours using the CIWA-Ar

  • Contact the medical officer or drug & alcohol nurse practitioner for assessment and monitor hourly if:

    • the alcohol score increases by at least 5 points over this 4-hour period, or

    • the CIWA-Ar total score reaches 10


Prepared by j mabbutt c maynard namo september 2008

7: Alcohol withdrawal scalesClinical Institute Withdrawal Assessment for Alcohol Revised Version (CIWA-Ar) (5)

Using the CIWA-Ar for hospitalised patients:

  • Monitor the patient 4-hourly, using the CIWA-AR, for at least 3 days

  • If the total score reaches 10, monitor hourly & notify the medical officer or drug & alcohol nurse practitioner


Prepared by j mabbutt c maynard namo september 2008

7: Alcohol withdrawal scalesAlcohol withdrawal scale (AWS) (1)

Alcohol Withdrawal Scale (AWS)

  • The AWS (see Appendix 3) is a widely used scale in NSW

  • If a patient’s history or presentation suggests possible withdrawal, the patient’s condition must be monitored & documented


Prepared by j mabbutt c maynard namo september 2008

7: Alcohol withdrawal scalesAlcohol withdrawal scale (AWS) (2)

  • The AWS (see Appendix 3) is a widely used scale in NSW and is a 7 item scale that allows a quantitative rating (from 0 to 4) of the following components:

  • Perspiration

  • Tremor

  • Anxiety

  • Agitation

  • Axilla temperature

  • Hallucinations

  • Orientation


Prepared by j mabbutt c maynard namo september 2008

7: Alcohol withdrawal scalesAlcohol withdrawal scale (AWS) (3)

Using the AWS in presentation to the emergency department:

  • Monitor the patient hourly for at least 4 hours using the AWS

  • Contact the medical officer or drug & alcohol nurse practitioner for assessment & monitor hourly if:

    • the alcohol score increases by at least 5 points over this 4-hour period, or

    • the AWS total score reaches 5


Prepared by j mabbutt c maynard namo september 2008

7: Alcohol withdrawal scalesAlcohol withdrawal scale (AWS) (4)

Using the AWS for hospitalised patients:

  • Monitor the patient 4-hourly, using the AWS, for at least 3 days

  • If the total score reaches 5, monitor hourly & notify the medical officer or drug & alcohol nurse practitioner

  • Depending on the resources of the local area, these may need review


Prepared by j mabbutt c maynard namo september 2008

7: Indications and guidelines:Pharmacological Treatment (1)

From NSW Drug & Alcohol Withdrawal Clinical Practice Guidelines NSW Health 2007

  • The most commonly prescribed pharmacological treatment for alcohol withdrawal is diazepam because of its cross-tolerance with alcohol & anti-convulsant properties

  • Two types of regimes for specialist residential or inpatient setting

  • Diazepam loading regime

  • Symptom-triggered sedation


Prepared by j mabbutt c maynard namo september 2008

7: Indications and guidelines:Pharmacological Treatment (2)

Diazepam loading regime

  • On the development of withdrawal symptoms initiate diazepam loading

  • 20mg initially, increasing to 80mg over 4-6 hours

  • Or until pt is sedated

  • Medial review required if dose exceeds 80mg & more diazepam can be ordered depending on withdrawal condition


Prepared by j mabbutt c maynard namo september 2008

7: Indications and guidelines:Pharmacological Treatment (3)

Symptom-triggered sedation

  • Mild withdrawal CIWA-AR <10 & AWS <4

  • Supportive care, observations 4 hourly

  • If sedation necessary; 5-10mg oral diazepam every 6-8 hours for first 48 hrs


Prepared by j mabbutt c maynard namo september 2008

7: Indications and guidelines:Pharmacological Treatment (4)

Symptom-triggered sedation

  • Moderate withdrawal CIWA-AR 10-20 & AWS <5-14

  • Medical officer to assess

  • If alcohol withdrawal confirmed: hourly observations; give 10-20 oral diazepam immediately; repeat 10mg hourly or 10-20mg 2hrly until the pt achieves good symptom control (up to a total dose of 80mg)

  • Repeat medical review after 80mg of diazepam and if pt is not settling, consider olanzepine (zyprexia) 5-10mg


Prepared by j mabbutt c maynard namo september 2008

7: Indications and guidelines:Pharmacological Treatment (5)

Symptom-triggered sedation

  • Severe withdrawal CIWA-AR 20+ & AWS 14+

  • Urgent management. Give a loading dose

  • Review more frequently until score falls

  • A rising score indicates a need for more aggressive management


Prepared by j mabbutt c maynard namo september 2008

7: Indications and guidelines:Pharmacological Treatment (6)

  • Contraindications to diazepam include:

    • respiratory failure,

    • significant liver impairment,

    • possible head injury or cerebrovascular accident – in these situations, specialist consultation is essential

      From NSW Drug and Alcohol Withdrawal Clinical Practice Guidelines NSW Health 2007 http://www.health.nsw.gov.au/policies/gl/2008/GL2008_011.html


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