Makindo Medical Notes.com

DT usually develops 48-72 h after the cessation of heavy drinking. Always ask when was last drink. Prevent it with the use of long-acting Benzodiazepines

Neurochemistry

• Alcohol is a potent central depressant and acts on NMDA and GABA receptors.
• Alcohol diet is low in thiamine which is key in many metabolic pathways
• Alcohol withdrawal leads to unopposed glutamate activity and excitotoxicity
• Cellular level there is intracellular calcium influx and oxidative stress

Clinical Syndromes

• DT presents with a combination of severe alcohol withdrawal symptoms and symptoms of delirium with agitation and sometimes hallucination
• May be known cirrhosis and alcoholic liver disease. Try and pre-empt the problem if known.
• Sometimes early signs show such as building agitation and this is a good time to get some Oral Diazepam or Chlordiazepoxide.
• Will build to extreme agitation, paranoia, picking at bed sheets, seeing rats and a hyper-adrenergic
• There is sweating, tachycardia, agitation, hyperactive delirium, insomnia.
• Withdrawal seizure which is usually Generalised Tonic Clonic can emerge any time after 24 h
• DT is a short lasting condition with a usual duration of 3-4 days
• Prevent before it reaches this state. There can be intense autonomic hyperreactivity.

Differential of Hyperactive Delirium to consider

• Alcohol withdrawal, Hypoglycaemia, Manic episode
• Sepsis, UTI, Meningitis, Chest
• Haemorrhage, Head trauma, Other drugs cocaine

Are there risk factors of severe withdrawal present? (Any ONE of the following)

• High alcohol intake (> 15units/day)
• History of severe withdrawal (includes seizures/DTs) USE CIWA to monitor
• High levels of anxiety or confusion Wernicke's Encephalopathy
• Use of other psychotropic drugs
• Psychiatric disorders Poor physical health
• Low blood sugars, Hypocalcaemia, Hypokalaemia
• Respiratory alkalosis

Investigations

• FBC, U&E, LFTS, CRP, Ca, Mg, Glucose, Clotting, Prothrombin time
• CT Head may be needed and Delirium screen.
• May need LP if history unclear and meningitis a concern
• Consider ABG if hypoxc or CO₂ narcosis suspected
• Ammonia if Hepatic encephalopathy suspected
• Echocardiography if cardiomyopathy suspected
• Blood cultures, Ascitic tap if ascites ? SBP
• MRI brain (if done usually with sedation) Associated head injury; T2 or FLAIR sequence is preferred; bilateral symmetrical hyper intensities seen in thalami, mamillary bodies, tectal plate and periaqueductal area in WE

Risk factors for poor outcomes

• Previous seizures/DTs
• Previous delirium, Infections, Co morbidities

Alcohol withdrawal scale (AWS)

• Somatic symptoms: Severity rating 0-3
  • Pulse rate (per min)
  • Diastolic blood pressure (mmHg)
  • Temperature
  • Breathing rate (per min)
  • Sweating
  • Tremor
• Mental symptoms: Severity rating 0-4
  • Agitation
  • Contact
  • Orientation (time, place. person, situation)
  • Hallucinations (optical, acoustic and tactile
  • Anxiety
• Total score is the combination of somatic and mental symptoms.
• Score < 5 is Mild withdrawal.
• Score 6-9: Moderate withdrawal.
• Score >9 Severe withdrawal

Actively monitor for early signs of DTs such as increased anxiety, irritability, tremor, hypertension, anorexia, nausea, vomiting, retching, agitation, hallucinations. Act fasts to ensure adequate sedation. Either use oral Chlordiazepoxide or if not an effective route consider IM Lorazepam and closely manage ABC. Get early help if GCS falls.

See Alcohol Withdrawal Assessment Scoring Guidelines

• Indications for PRN medication:
  • a. Total CIWA-AR score 8 or higher if ordered PRN only (Symptom-triggered method).
  • b. Total CIWA-AR score 15 or higher if on a reducing regime. (Reducing regime + PRN method)
• For Senior review if : Total score above 35, if hourly assessment required for more than 8hrs, more than 4 mg/hr lorazepam over 3 hours, or respiratory distress.

Management

• Admit to a medical bed in a supportive quiet well-lit calm area if possible. Alcohol is a CNS depressant and removal leads to cerebral overactivity and seizures. If GCS falls due to sedation consider HDU bed and close monitoring. Risks are seizure and aspiration and respiratory sedation and falls. Some patients do not develop DTs and need little if any sedation. The key is close monitoring and escalation and availability of PRN medications and nursing and medical team who can spot early signs and initiate treatment.
• ABC, Recovery position if GCS fall and consider NP airway if tolerated. Monitor NEWS score, Correct dehydration. Consider PPI and Antiemetics if sick. Correct Mg and K and Ca, treat infection, pain, urinary retention or other acute issues
• IV Pabrinex (I/II pairs) for 5 days should be given to prevent confusion, ataxia, ophthalmoplegia (Wernickes) and Wernicke-Korsakoff syndrome. Must be given before glucose and nutrition. Then start Oral Thiamine.
• Commence a Benzodiazepine at an effective dose first based on clinical evaluation. Long-acting BDZs (like diazepam, chlordiazepoxide) are preferred over the short-acting ones because of their potential for self tapering and constant serum level. Benzodiazepines mimic the GABA modulating effects of ethanol and are safe and effective. The following doses can be titrated up or down as needed. Benzodiazepines needed for 3-5 days.
  • Chlordiazepoxide 20-40 mg 6-8 hourly for 24 hrs with PRN doses also then 2 days of 15 mg 6-hourly and slowly reduce. Patients with liver disease, respiratory depression, frailty renal failure or over 70 yrs old may need lower doses of Chlordiazepoxide or use Lorazepam. Higher doses for those with clinical signs of DTs such as anxiety, irritability, tremor, hypertension, anorexia, nausea, vomiting, retching, agitation, hallucinations. Act fasts to ensure adequate sedation. If the medication leads to excess sedation involve critical care and admit to an HDU bed if possible for close monitoring and titration of medications.
  • Diazepam 10 mg PO 8 hourly for 24 hrs then 2 days of 5mg 8-hourly. Ensure PRN doses are available so that dosing can be stepped up.
  • Lorazepam 2-4 mg IM may be useful when IM access is all that is available. Avoid Phenytoin. Titrate dose to the situation.
  • Haloperidol may be used for agitation but is generally avoided if possible. It is not advised as a sedative in this scenario as can lower the seizure threshold
• If GCS <=9 then consider HDU admission. Propofol has been used especially if intubation and ventilation needed
• Enlist anaesthetic critical care input if GCS<9 or high NEWS score or recurrent seizures/status. Consider HDU admission. The main concern is airway issues, sedation, hypoxia and aspiration.

References

• Delirium Tremens: Assessment and Management 2018