Alcohol Withdrawal

Summary Flowchart

For guidance on thiamine in refeeding syndrome see Guidance on thiamine replacement in patients at risk of Refeeding Syndrome

Inpatient referrals

1. Refer to Addiction Liaison Service via Cortix or by phoning 33090
2. Patients should be aged 18 or over and medically fit to be seen and engage with service
3. Patients with alcohol withdrawal and suicidal ideation or significant mental health issues should be referred to Acute Liaison Psychiatry as well as Addiction Liaison Service
4. Patients discharged before they can be seen by Addiction Liaison eg at weekends should be given number for NHS Drug and Alcohol Service – 01387 244555
5. Patients presenting with cannabis/cocaine/other recreational drug use rather than alcohol withdrawal should be referred to Addaction for follow up following discharge – 01387 263208 (Dumfries) or 01776 705907 (Stranraer).

Alcohol Withdrawal Syndromes

1. Alcohol withdrawal usually begins within 6-8 hours after an abrupt reduction in heavy drinking
2. Can be earlier in severe dependence or may not manifest for up to 72 hours
3. Can develop before the blood alcohol level has fallen to zero.
4. Generally peaks within 10-30 hours and lasts for 3-7 days

Alcohol Withdrawal Syndromes

Assessment and General Management

1. Calculate alcohol intake- see below
2. Screen for dependence – FAST score – see below
3. Assess severity of withdrawal using Glasgow Modified Alcohol Warning Score (GMAWS) – see below
4. Look for stigmata of chronic liver disease
5. Consider other possible causes of confusion in an alcohol dependent patient – see below
6. Check FBC, U&E, LFTs including GGT & AST, BG, CaPO₄, Mg and coag screen, blood alcohol level may also be useful.
7. Maintain 2-2.5litres intake per day using IV if necessary
8. Ensure good lighting and cool ambient temperature, good ventilation, supportive nursing, reassurance, single room if confused
9. Consider ear plugs if difficulty sleeping (can be sourced from H@N Nurses)
10. Prescribe Pabrinex and Benzodiazepines as per protocol

Possible Causes of Confusion in an Alcohol Dependent Patient

1. Acute alcohol intoxication
2. Alcohol withdrawal including Delirium tremens
3. Hypoglycaemia
4. Head injury
5. Subdural haematoma
6. Wernicke’s encephalopathy
7. Hepatic encephalopathy
8. Septicaemia
9. Meningitis including TB meningitis
10. Concurrent illicit substance abuse.

Calculating Alcohol Intake

Fast Alcohol Screening Tool – FAST

Glasgow Modified Alcohol Warning Score (GMAWS) Screening Tool

Symptom Triggered GMAWS Management

Fixed Dose Diazepam Regimen

Use Lorazepam for Higher Risk Groups

1. Patients with evidence of liver disease, especially jaundice, ascites, encephalopathy
2. Patients with other co-morbidities eg COPD, pneumonia, cerebrovascular disease, head injury, reduced GCS, elderly over 70 years, head injury.
3. Patients with co-prescribed CNS sedative drugs eg opiates
4. Use oral lorazepam in these groups in a symptom-triggered fashion: 1-2mg to a maximum of 12mg in 24 hours before requesting senior medical review. Give IM or SC if unable to swallow.
5. Patients on lorazepam may require more frequent monitoring and PRN doses due to shorter half life

Aggressive/uncontrollable/dangerous behaviour

1. 1. Move patient to Critical Care
   2. Follow dosing schedule for IV diazepam or IV lorazepam in table below
      

      Patient with severe or decompensated lver disease/respiratory disease/head injury?
      NO	YES
      Diazepam emulsion (Diazemuls®) via large vein	Lorazepam IV
      5mg	1mg
      Insufficient/no response after 5-10 min
      5mg	1mg
      Insufficient/no response after 5-10 min
      10mg	2mg
      Insufficient/no response after 5-10 min
      10mg	2mg
      Insufficient/no response after 5-10 min
      20mg	2mg
      Insufficient/no response after 5-10 min
      Continue as above at 20mg doses	Continue as above at 2-4mg
      If response not achieved at 120mg diazepam (or 12mg Lorazepam) seek senior medical advice & consider Haloperidol 3-5mg IM every 30-60minutes (max 18mg/24hours)
      Once settled continue at 5-20mg diazepam (1-2mg Lorazepam) every hour to maintain light somnolence

   3. Have flumazenil available
   4. Diazepam 120mg or lorazepam 12mg over 24 hours is unlikely to cause problems in an uncomplicated patient
   5. Consider adjunctive therapy with haloperidol 3-5mg IV or IM (smaller doses unlikely to be effective) if still not settling (minimum 4 hourly, max 12-18mg/24 hours)
   6. Once settled continue 5-20mg diazepam (1-2mg lorazepam) per hour to maintain light sedation
   7. Consider need for glucose and magnesium, but do not give glucose until after Pabrinex.
   8. In extreme cases where very high dose parenteral diazepam >200mg is ineffective it may be necessary to incubate.

Patients Unable to Tolerate Oral Medication

1. Patients unable to tolerate oral medication may receive IV therapy (Diazemuls or lorazepam) as an alternative at 50% of the oral dose in the first instance and response assessed.
2. It is recommended that IV benzodiazepines are administered by an experienced member of staff (FY2 or above).

Monitoring

1. All patients should be closely observed for signs of oversedation
2. Higher risk groups (see above), patients with severe withdrawal and patients requiring intravenous or intramuscular sedation require close monitoring (pulse, blood pressure, respiratory rate, GCS, oxygen saturation), ideally with one-to-one nursing care.
3. Consultation regarding intensive care support may be necessary in extreme situations.
4. If patient is only on symptom triggered GMAWS and is scoring 3 or less after 72 hours then symptom triggered treatment can be stopped

Approximate Oral Benzodiazepine Equivalence

1. 10mg diazepam = 1mg lorazepam = 30mg chlordiazepoxide.

Medication on Discharge

1. Do not discharge on regular benzodiazepine unless arrangement confirmed with community addiction services or Alcohol Liaison Nurse.  See Hippo (link below) for advice on discharging detox patients.
2. Chlordiazepoxide is the recommended benzodiazepine for community use.
3. All patients should go home on Thiamine 50mg qds.

Content updated by Alison Moore & Chris Isles