By: David Bridgers, M.D.
43 y/o AAM with a hx, HTN, and long term ETOH abuse, who presented to the Urology service after being seen in the ED for Hematuria, and being diagnosed with a renal mass. He was 1 day s/p nephrectomy. He was on epidural pain medications per pain control. He was reported to be agitated when the nursing staff evaluated him.The
The Urology team evaluated the patient and after realizing that he had not had a drink in 36 hours they called for a Medicine consult for management of DTs.
Minor Withdrawal Symptoms:
-occur w/i 6 hours of cessation
-insomnia, tremulousness, mild anxiety, GI upset, diaphoresis, HA, palpitations, and anorexia.
-usually resolve w/i 24-48 hrs.
-vary from episode to episode
-w/i 48 hours of last drink
-3% of chronic alcoholics develop this
-3% of those who seize develop Status Epilepticus
- 12- 24 hr. onset after last drink
- usually visual
- Resolve w/i 24-48 hr.
- NOT synonymous with DT’s
*other signs may or may not be present
* time course is different
* not usually associated with clouding of the sensorium
- 5% of patients who withdraw
- typically begin b/w 48 and 96 hours
- typically last 1-5 days
- longer periods requiring massive doses of medications have been described (Wolf et. Al 1993)
- Early figures of associated mortality were as high as 37%
- Now mortality is felt to be 5%. This is likely due to earlier diagnosis, improved pharmacological, and non-pharmocologic management, and improved treatment of co-morbid conditions.
-Mortality risk is greater:
2. Concomitant lung Dz
3. Core body temp >104
4. Co-existing liver Dz.
- Death is usually due to arrhythmia or secondary complications. (pneumonia,liver failure)
-Ideally a quiet and protective setting, unless pt. Is at higher risk for complications, then they should be in a ICU.
- JAMA July 9,1997
- Goal was to establish evidence based guidelines for the treatment of Alcohol withdrawal syndromes
1. Severity of withdrawal syndrome
2. Alcohol Withdrawal Delirium
3. Withdrawal Seizures
4. Completion of withdrawal
5. Entry into Rehab
- Structured Severity Assessment Scale
-Objective Scale for use by health care personel to evaluate patients at risk for developing alcohol withdrawal syndromes, and quantify the severity of withdrawal.
Dosing Schedules which are acceptable:
1. Fixed - most useful in high risk pts.
2. Symptom Triggered - Based on certain CIWA-Ar scores.
3. Front Loaded - Auto taper method. Not in Working Group Recommendations, but supported by other studies
1. Long acting may be more effective in controlling seizures
2. Long acting contributes to smoother withdrawal and less rebound
3. Short acting have lower risk of oversedation
4. Certain Benzos have higher potential for abuse
5. Cost varies considerably
1. Mild Symptoms (CIWA-Ar score <8-10) reasonable option is non-pharmacological supportive therapy and cont. monitoring.
Moderate Symptoms (score 8-15) symptomatic administration of medications, with hourly assessment. Regimen recommended :
1.Librium 50-100 mg
2.Valium 10-20 mg
3.Ativan 2-4 mg.
Severe Symptoms (score >15) - Provide Fixed scheduled medications in the amounts necessary to control symptoms. Regimen Recommended:
1.Librium:50 mg q 6 hrs. x 4 doses then 25 mg q 6 hrs. x 4 doses
2.Valium: 10 mg q 6 hrs. x 4 doses then 5 mg q 6x 8 doses
3.Ativan: 2 mg q 6 x 4 doses then 1 mg q6 x 8 doses.
Additional PRN dosing if necessary
2. For pts. With a hx of Sz. Provide 1 of the proposed fixed regimens on presentation, regardless of the severity of withdrawal.
(monitoring and symptomatic tx is reasonable)
3. Early treatment of those with severe co-morbidities is warranted.
Pt. was seen by the internal medicine consult team. He was found to be mildly sedated from pain medicines but would answer questions. He had mild pain from incision site, but otherwise had no tremors, nausea, diaphoresis, or signs of anxiety/agitation. He had no visual or auditory hallucinations. Physical exam was benign.
The CIWA-Ar score was used in assessing the patient, and he was found to have a CIWA-Ar of 0. The urology team was notified of findings and a copy of the CIWA-Ar scale was applied to his chart.