Alcohol withdrawal: Difference between revisions
From IDWiki
m (Text replacement - "Clinical Presentation" to "Clinical Manifestations") |
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== Background == |
== Background == |
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− | === Risk |
+ | === Risk Factors for Severe Withdrawal === |
*Severity predicted by [[PAWSS scale]]: if score ≤3 can manage as outpatient |
*Severity predicted by [[PAWSS scale]]: if score ≤3 can manage as outpatient |
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==Management== |
==Management== |
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− | * |
+ | * Given the balance of risks (minimal) and benefits (potentially large), almost all patients treated for alcohol withdrawal should receive supplemental [[thiamine]] |
** Standard: 250 mg IM/IV q24h x3d |
** Standard: 250 mg IM/IV q24h x3d |
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**High-dose: 500 mg IV q8h x3 |
**High-dose: 500 mg IV q8h x3 |
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− | === Benzodiazepine |
+ | === Benzodiazepine Protocols === |
*If history of seizures: [[diazepam]] 20mg q1h x3 doses before starting CIWA |
*If history of seizures: [[diazepam]] 20mg q1h x3 doses before starting CIWA |
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**Discontinue [[CIWA-Ar]] protocol after two consecutive scores <10 |
**Discontinue [[CIWA-Ar]] protocol after two consecutive scores <10 |
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− | === Phenobarbital |
+ | === Phenobarbital Protocols === |
− | ==== General |
+ | ==== General Protocol ==== |
− | * Load 10 mg/kg IV up front over 30min (if has not received significant benzodiazepines) |
+ | * Load [[phenobarbital]] 10 mg/kg IV up front over 30min (if has not received significant benzodiazepines) |
* Then give 130-260 mg IV prn for mild to severe withdrawal symptoms |
* Then give 130-260 mg IV prn for mild to severe withdrawal symptoms |
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* Titrate to effect; there is no maximum dose |
* Titrate to effect; there is no maximum dose |
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==== CAMH protocol ==== |
==== CAMH protocol ==== |
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− | * Loading: phenobarbital 120 mg po q1h until phenobarbital loading effect score is 3 to 4, then stop loading |
+ | * Loading: [[phenobarbital]] 120 mg po q1h until phenobarbital loading effect score is 3 to 4, then stop loading |
− | * Maintenance: phenobarbital 60 mg po qid |
+ | * Maintenance: [[phenobarbital]] 60 mg po qid |
* Taper: |
* Taper: |
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− | ** Decrease by 30 mg each day from a starting dose of phenobarbital 60 mg po qid |
+ | ** Decrease by 30 mg each day from a starting dose of [[phenobarbital]] 60 mg po qid |
** 60/60/60/60, 60/30/60/60, 60/30/30/60, 60/30/30/30, 30/30/30/30, 30/–/30/30, 30/–/–/30, 30/–/–/–, stop |
** 60/60/60/60, 60/30/60/60, 60/30/30/60, 60/30/30/30, 30/30/30/30, 30/–/30/30, 30/–/–/30, 30/–/–/–, stop |
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** Takes 8 days |
** Takes 8 days |
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− | * Phenobarbital loading effect scale |
+ | * [[Phenobarbital]] loading effect scale |
− | ** Nystagmus: absent (0); present on extension of lateral gaze (1); easily elicited and sustained (2); coarse, sustained nystagmus (3) |
+ | ** [[Nystagmus]]: absent (0); present on extension of lateral gaze (1); easily elicited and sustained (2); coarse, sustained nystagmus (3) |
− | ** Dysarthria: absent (0); minor slurring of some words (1); moderate slurring frequently (2); severe slurring, unintelligible (3) |
+ | ** [[Dysarthria]]: absent (0); minor slurring of some words (1); moderate slurring frequently (2); severe slurring, unintelligible (3) |
− | ** Ataxia: absent (0); mildly unsteady on tandem gait (1); moderately unsteady on regular gait (2); needs support on regular gait (3) |
+ | ** [[Ataxia]]: absent (0); mildly unsteady on tandem gait (1); moderately unsteady on regular gait (2); needs support on regular gait (3) |
** Emotional lability: normal, as before loading (0); some mood change (1); obvious mood change, inappropriate (2); uninhibited, mood swings (3) |
** Emotional lability: normal, as before loading (0); some mood change (1); obvious mood change, inappropriate (2); uninhibited, mood swings (3) |
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Revision as of 22:11, 29 December 2021
Background
Risk Factors for Severe Withdrawal
- Severity predicted by PAWSS scale: if score ≤3 can manage as outpatient
- History of alcohol withdrawal, especially if previously severe (e.g. delirium tremens)
- Age
- Alcohol tolerance
- Concurrent sedative medications
- Major medical comorbidities
- Drinking all day long
Clinical Manifestations
- 6 to 12 hours after last drink: shaking, headache, sweating, anxiety, nausea, or vomiting
- 12 to 24 hours after last drink: confusion, hallucinosis (with awareness of reality), tremor, or agitation
- 24 to 48 hours after last drink: seizures
- 48 hours after last drink: delirium tremens, high blood pressure, and fever
- Can persist anywhere from 4 to 12 days
Investigations
- Monitor electrolytes and extended electrolytes for refeeding syndrome
Management
- Given the balance of risks (minimal) and benefits (potentially large), almost all patients treated for alcohol withdrawal should receive supplemental thiamine
- Standard: 250 mg IM/IV q24h x3d
- High-dose: 500 mg IV q8h x3
Benzodiazepine Protocols
- If history of seizures: diazepam 20mg q1h x3 doses before starting CIWA
- Can use diazepam, lorazepam (if liver disease), or Chlordiazepoxide
- Start CIWA-Ar (Clinical Institute Withdrawal Assessment - Alcohol revised) q1h
Phenobarbital Protocols
General Protocol
- Load phenobarbital 10 mg/kg IV up front over 30min (if has not received significant benzodiazepines)
- Then give 130-260 mg IV prn for mild to severe withdrawal symptoms
- Titrate to effect; there is no maximum dose
- Maintenance with 100-200 mg PO/IM q1h prn
CAMH protocol
- Loading: phenobarbital 120 mg po q1h until phenobarbital loading effect score is 3 to 4, then stop loading
- Maintenance: phenobarbital 60 mg po qid
- Taper:
- Decrease by 30 mg each day from a starting dose of phenobarbital 60 mg po qid
- 60/60/60/60, 60/30/60/60, 60/30/30/60, 60/30/30/30, 30/30/30/30, 30/–/30/30, 30/–/–/30, 30/–/–/–, stop
- Takes 8 days
- Phenobarbital loading effect scale
- Nystagmus: absent (0); present on extension of lateral gaze (1); easily elicited and sustained (2); coarse, sustained nystagmus (3)
- Dysarthria: absent (0); minor slurring of some words (1); moderate slurring frequently (2); severe slurring, unintelligible (3)
- Ataxia: absent (0); mildly unsteady on tandem gait (1); moderately unsteady on regular gait (2); needs support on regular gait (3)
- Emotional lability: normal, as before loading (0); some mood change (1); obvious mood change, inappropriate (2); uninhibited, mood swings (3)