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CDHB

Alcohol Withdrawal

• During alcohol withdrawal the following symptoms may be seen:
  • Sweating, tremor, anxiety, agitation, nausea and vomiting, hallucinations, disorientation, headaches, facial flushing, and seizures.
  • Record which of these are present and if so, the severity and/or frequency.
  • See Alcohol Withdrawal Scale (AWS) (search for "C240008" on the CDHB intranet).

Immediate Treatment

• Administer thiamine 100 mg IM or IV before glucose is given. Many patients with alcohol dependence are thiamine deficient and glucose infusions may precipitate Wernicke's encephalopathy. The classic features of Wernicke's encephalopathy are not always present and mild confusion may be the only manifestation. Always consider giving thiamine 100 mg IM stat in patients with alcohol dependence presenting to hospital and for all patients with undiagnosed seizures, confusion, stupor and coma.
• Attention to fluids, electrolytes, hypoxia.
• Alcoholic hallucinations - haloperidol 2 mg IM then 1-3 mg BD IM maintenance. Oral therapy when appropriate.

  Note: Haloperidol may provoke seizures or hypotension. Give lower doses in the elderly.

Early Withdrawal: AWS ≤10

• Limit all external stimuli, such as noise and visitors. Regularly re-orientate patient to the day, date, and their whereabouts, and explain the symptoms they may be experiencing. If the patient is confused (delirium) or agitated, they are at increased risk of personal injury and should be observed closely. Nurse the patient at floor level, if appropriate, to reduce the risk of falls and/or wandering off. If further treatment is required, see below.

Moderate to Severe Withdrawal: AWS >10 - Diazepam Loading

• For patients without concurrent disease give diazepam 20 mg orally every 1-2 hours for 3-4 doses (60-80 mg) to achieve light sedation, and then stop. Re-assess after four hours.
• Because of the long half-life of diazepam, it is usually unnecessary to sedate further.
• If further doses are required due to the AWS score, give 5-10 mg every six hours if needed, and taper off after 3-5 days.
• A maximum daily dose of 120 mg of diazepam is generally sufficient, unless the case is especially severe, which should prompt the exclusion of other underlying conditions.
• If at high risk of seizures, consider also carbamazepine 400 mg PO stat then 200 mg TDS PO for 5 days. Some authorities recommend phenytoin or sodium valproate in this situation.

Note: Consider dose reduction in the elderly, frail and those with liver impairment.

Alcohol Withdrawal Seizures

• Seizure treatment: a previous history of withdrawal seizures denotes a significant likelihood of their recurrence. In those exhibiting seizures for the first time, blood sugar and neurological investigations (especially in head injury) should be undertaken before they are attributed to alcohol withdrawal. Treat seizures with:
  • 10 mg diazepam IV bolus injection, given slowly (can be repeated up to twice in first 30 minutes).
  • Thereafter give 10-20 mg diazepam by slow IV injection every six hours; or a maintenance dose of 1-3 mg per hour via continuous infusion. After 24 hours patients can be changed to oral medication.
  • For continuous seizures or status epilepticus consider IV anti-convulsants, such as IV phenytoin or IV valproate using IV loading dose and subsequent infusions.

Note: Refer to the Neurology section for full seizure treatment details.

Wernicke's Encephalopathy

• If Wernicke's encephalopathy is present or suspected, give:
  • Thiamine 400 mg IV or IM TDS for 2 days, then 200 mg IV or IM daily for a further 5 days.
  • Vitamin B Complex 2 tabs PO BD. This preparation contains vitamins B1, B2, B3, and B6.
  • A multivitamin preparation once daily.
• All patients should be given long term treatment with thiamine 100 mg BD PO and Vitamin B Complex 1 tab BD PO and a multivitamin tablet daily.

Topic Code: 1295