Makindo Medical Notes

Alcohol Withdrawal (Delirium Tremens) typically develops 48-72 hours after cessation of heavy drinking. Always ask when the last drink was consumed. Prevent DTs with long-acting benzodiazepines.

Alcohol Withdrawal Scale (AWS)

• Somatic Symptoms (0-3): pulse rate, diastolic BP, temperature, respiratory rate, sweating, and tremor.
• Mental Symptoms (0-4): agitation, contact, orientation, hallucinations, anxiety.
• Scoring:
  • Score <5: Mild withdrawal
  • Score 6-9: Moderate withdrawal
  • Score >9: Severe withdrawal

CIWA-Ar Scale

The CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol Scale, Revised) helps guide treatment by assessing withdrawal severity. Each symptom is rated from 0 (absent) to 7 (most severe), with a maximum total score of 67. Symptom-triggered benzodiazepine treatment is based on score severity:

• Score 0-8: Minimal withdrawal; generally no medication required.
• Score 9-14: Mild withdrawal; consider benzodiazepines.
• Score 15-20: Moderate withdrawal; benzodiazepine treatment indicated.
• Score >20: Severe withdrawal; intensive treatment needed, often with frequent benzodiazepine dosing and possible ICU monitoring.

CIWA-Ar Items and Scoring

1. Anxiety (0-7): Rate patient's level of nervousness.
2. Agitation (0-7): Rate physical agitation.
3. Auditory Disturbances (0-7): Rate perception of sounds and noises.
4. Orientation and Clouding of Sensorium (0-4): Awareness of self, time, place.
5. Paroxysmal Sweats (0-7): Rate sweating intensity.
6. Tactile Disturbances (0-7): Perception of skin sensations (e.g., itching).
7. Tremor (0-7): Rate tremor severity in hands and arms.
8. Visual Disturbances (0-7): Rate perception of visual hallucinations.
9. Headache (0-7): Rate severity of headache.
10. Nausea and Vomiting (0-7): Rate presence of nausea/vomiting.

**Indications for PRN medication**: Total CIWA-Ar score of 8 or higher (symptom-triggered), or score of 15 or higher if on a reducing regime.

Neurochemistry

• Alcohol is a CNS depressant that affects NMDA and GABA receptors.
• Chronic alcohol use depletes thiamine, essential for several metabolic pathways.
• Withdrawal causes unopposed glutamate activity, excitotoxicity, and cellular oxidative stress.

Management

• Supportive Care: Admit to a calm, well-lit room. Monitor vitals, correct dehydration, and provide nutrition and thiamine.
• IV Pabrinex: 2 pairs immediately, TDS for 5 days to prevent Wernicke-Korsakoff syndrome. Administer before glucose.
• Benzodiazepines:
  • Chlordiazepoxide 20-40 mg PO every 6-8 hours for 24 hours, then taper over 3-5 days.
  • Diazepam 10 mg PO 8-hourly for 24 hours, then reduce to 5 mg 8-hourly.
  • Lorazepam 2-4 mg IM if oral access is unavailable.
• CIWA-Ar monitoring: Reassess CIWA-Ar every 1-4 hours, adjusting benzodiazepine dose based on symptom severity.
• Avoid haloperidol as it lowers the seizure threshold.

Risk Factors for Severe Withdrawal

• High alcohol intake (>15 units/day)
• Previous history of seizures/DTs or severe withdrawal
• Comorbid psychiatric or physical conditions

Investigations

• FBC, U&E, LFT, CRP, calcium, magnesium, glucose, coagulation profile.
• CT head if altered mental status persists, or if head trauma is suspected.

References

• Delirium Tremens: Assessment and Management 2018