Alcohol Withdrawl

Generally we DON’T admit patients acutely solely for “Detox”

However the following groups should be admitted [taken from trust guide]

  • Patients requiring admission for another reason – refer to appropriate specialty (e.g.  Head injury going to CDU, or Upper GI bleed going to medicine)
  • ALL patients with symptoms / signs of Wernicke’s – medicine
  • ALL patients with Delirium Tremens – medicine
  • ALL alcohol withdrawal fits if patient to remain abstinent – medicine
  • ALL alcohol related seizures with possible other trigger – medicnie
  • ALL decompensated alcoholic liver disease – medicine

If admitted to CDU – complete the PAT tool

Chlordiazepoxide

The following is a guide and the dose should be regularly reviewed – (CIWA-Ar is recommended to aid reviews)

Discharge: patients should not be sent home with >3 doses of chlordiazepoxide [unless agreed with community services]

 

Wernicke’s Encephalopathy

Wernicke’s has a mortality of 10-20%, so should be looked for, and treated appropriately

Signs/Symps

  • Acute peripheral neuritis
  • Alcohol withdrawal fits
  • Ataxia – not due to intoxication
  • Confusion/Coma/Reduced Consciousness – not due to intoxication
  • Delirium Tremens
  • Hypotension
  • Hypothermia
  • Memory disturbance
  • Ophthalmoplegia – paralysis of the extra-ocular muscles controlling eye movements
  • Physically unwell

Managment

  • Treatment (under medicine) – Pabrinex 2 pairs, TDS, 2 Days (followed by prophylaxis regime)
  • Prophylaxis – Pabrinex 1 pair, OD, 3-5days while requiring admission, then Thiamine 100mg TDS.
  • Decompensated Liver Disease – Add Lactulose 15ml BD (aim 2-3 stool/day)

Delerium Tremens (DT’s)

This the most severe end of the withdrawal spectrum, and tends to come on suddenly 48-72 hours after stopping (or significant reduction) of alcohol consumption. It is typified by autonomic hyperactivity (Mortality is 15-35%).

Signs/Symps

  • Agitation
  • Confusion (Profound)
  • Hallucinations(visual/auditory/tactile)
  • Fever
  • Tachycardia
  • Hypertension
  • Heavy sweating

Managment

  • Admission – Medicine, will need close monitoring
  • Chlordiazepoxide – Reducing regime & PRN
  • Pabrinex – 2 pairs, TDS
  • Seizures – Standard therapy with early benzodiazepines

Arranging Follow Up

AUDIT SCORE RISK CATEGORY DESIRED ACTION – Calculator
0 –7 Lower risk – No intervention required
8 –15 Increasing risk – Brief Advice/offer Brief Intervention
16-19 Higher risk – Extended BA/Intervention
20+ Possible dependence – Referral to services

Those requiring follow up – copy of the assessment and patient details can be left in the drug&alcohol box in majors area, for the alcohol liaison team

 

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