Alcohol Withdrawal Syndromes

Clinical Description

These occur following sudden withdrawal from alcohol. They are often seen 12 to 18 hours after the last drink, but may be earlier and are worst between 24 to 48 hours after onset. This commonly occurs in patients admitted to hospital for other problems e.g. arising from accidents or physical illnesses, which keeps them from drinking. The presentation varies from minimal tremors to states of full-blown agitation and confusion, which are potentially fatal. Caused by abrupt cessation or significant reduction in alcohol intake in an individual with heavy drinking over many months or years

Signs and Symptoms

Minor Withdrawal Alcoholic Hallucinosis Alcoholic Seizures Onset 12 to 18 hours after last drink, but may be earlier. Peaks between 24-48 hours 12-24 hrs after cessation of drinking and generally stops within 48 hours 7-36 hours after the last drink but may be earlier.

• Headache
• Nausea
• Anxiety
• Fevers
• Shaking
• Tremor
• Sweating
• Vomiting
• Increased pulse and blood pressure
• Agitation
• In severe cases will progress to Delirium Tremens which presents with: confusion, marked agitation, aggression, hallucinations (frequently visual), delusions, seizure and autonomic instability

Investigations

• Full physical examination including vital signs (to exclude other causes of delirium if present)
• Consider FBC, LFT
• Random blood sugar

Treatment

• The aim of treatment is to reduce the symptoms associated with alcohol withdrawal, which can result in seizures and potentially be fatal
• A reducing course of oral Diazepam should be given four times a day, over five to seven days, titrated according to symptom resolution: for example:
• Diazepam 20mg 6 hourly for 1 day
• Diazepam 15mg 6 hourly for 1 day
• Diazepam 10mg 6 hourly for 1 day
• Diazepam 5mg 6 hourly for 1 day
• Diazepam 5mg 12 hourly for 1 day
• Diazepam 5 mg 24 hourly 1 day, It should be accompanied by oral Thiamine supplements
• Thiamine 100mg 24 hourly orally for 1 month

Secondary /alternative treatment

• If markedly agitated and unable to comply with oral medication IV Diazepam 5-10mg can be used up to 4 times per day until able to comply with oral treatment

Red Flags

• High dose IM / IV thiamine can be given if available
• IV fluids may be required if evidence of dehydration (low BP, tachycardic)

For admission:

• Delirium tremens should be treated as an inpatient (medical emergency)
• People with a high risk of seizures e.g., previous seizures, known epilepsy,
• People with co-morbid physical illnesses e.g., HIV, jaundice

Note: The dose of Diazepam should be reduced in the physically frail or those with liver impairment or alternatively use lorazepam.

Follow-up

• Once detoxification complete offer advice regarding safe levels of alcohol intake and counseling support if planning to stop drinking. Refer to alcoholic anonymous

Complications and Referral Criteria

• Refer all patients with alcohol withdrawal syndromes to a psychologist or psychiatrist.

Also refer all children to a paediatrician.

• Acute confusional state that occurs within hours to days of cessation, or reduction of alcohol intake after prolonged (weeks to months) / heavy consumption
• The peak onset is at 24-48 hours post last ingestion and it can last for 7 - 10 days if untreated