Acute Alcohol Withdrawal

Authors: David Patrick Ross, Scott Dickson, Kelly Kwok, Isla Waterson, Luke Zhu / Editors: Donogh Maguire, Ewan Forrest / Reviewer: Beth Newstead / Codes: / Published: 09/11/2018

Alcohol withdrawal is a common presentation to UK Emergency Departments (ED) and patients can present significant management challenges to clinicians. This session will give ED staff knowledge of the pathophysiology, identification, management and common pitfalls encountered in patients suffering from alcohol withdrawal.

Learning objectives

After this session it is anticipated that users will be able to:

• Define what is meant by alcohol withdrawal syndrome and delirium tremens
• Understand the pathophysiology of alcohol withdrawal
• Manage alcohol withdrawal 
• Briefly describe other complications of alcohol use disorder 

References:

1. WHO Regional Office for Europe. Progress report on implementation of the European Action Plan to Reduce the Harmful Use of Alcohol 2012-2020. 2017.
2. What is the burden of alcohol-related injuries in an inner city emergency department? J, Hoskins R. Benger. 3, 2012, Emergency Medicine Journal, 30.
3. NHS National Services Scotland. Alcohol-Related Hospital Statistics 2015/16. 2016.
4. The course of alcohol withdrawal in a general hospital. Foy, A. Kay, J. Taylor, A. 1997, QJM: An International Journal of Medicine , 90, pp. 253-261
5. Quantification of the alcohol withdrawal syndrome in 487 alcoholic patients. Benzer, D. 7, 1990, Journal of Substance Abuse Treatment, pp. 117-123.
6. American Psychiatric Association. Diagnostic and statistical manual of mental disorders 5 th Edition. 2013
7. World Health Organisation. The ICD-10 Classification of Mental and Behavioural Disorders: Diagnostic Criteria for Research 2017.
8. Alcoholic Hallucinosis: a psychiatric enigma. The Development of an Idea. Glass, I. 1989,British Journal of Addiction. 84, pp29-41
9. Alcohol withdrawal syndrome: mechanisms, manifestations, and management. Jesse, S. Brathen, G. Ferrare, M. Keindl, M. Ben-Menachem, E. Tanasescu,R. Brodtkorb, E. Hillbom, M. Leone, M. Ludolp, A. 2016. Acta Neurologica Scandinavia. 135. pp 4-16
10. National Institute for Clinical Excellence. Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence. 2011
11. Royal College of Emergency Medicine. Alcohol: A toolkit for Improving Care. 2015
12. Prospective validation study of the Prediction of Alcohol Withdrawal Severity Scale (PAWSS) in medically ill inpatients: A new scale for the prediction of complicated withdrawal syndrome. Maldonado, J. Sher, Y. Das, S. Hills-Evans, K. Frenklack, A. Lolak, S.Neri, E. 5, 2015, Alcohol and Alcoholism, 50, pp.509-518.
13. Development of a rating scale to predict the severity of Alcohol Withdrawal Syndrome. Wetterling, T. Weber, B. Depfenhart, M. Schneider, B. Junghann, K. 6, 2006, Alcohol and Alcoholism, 41, pp. 611-615.
14. The Alcohol Use Disorder Identification Test predicts alcohol withdrawal symptoms during inpatient detoxification. Reuox, J. Malte, C. Kivlahan, D. Saxon, A. 4, 2002, Journal of Addictive Diseases, 21, pp.81-91.
15. Combining the AUDIT questionnaire and biochemical markers to assess alcohol use and risk of alcohol withdrawal in medical inpatients. Dolman, J. Hawkes, N. 6, 2005, Alcohol and Alcoholism, 2005,40. pp. 515-519.
16. Using the AUDIT-PC to predict alcohol withdrawal in hospitalized patients. Pecoraro, A. Ewen, E. Horton, T. Mooney, R. Kolm, P. McGraw, P. Woody, G. Journal of Genera Internal Medicine. 135, 2013, 29. pp. 34-40.
17. NHS Greater Glasgow and Clyde. Adult Therapeutics Handbook: Management of Alcohol Withdrawal Syndrome. 2018.
18. Haydel, M. Preston, C. Mills, T. Luber, S. Blaudeau, E. DeBlieux, P. Indications for Computed Tomography in Patients with Minor Head Injury. 2000. New England Journal of Medicine, 343, pp 100-105
19. Johnston, J. McGovern, S. Alcohol related falls: an interesting pattern of Injuries. 2004. Emergency Medicine Journal, 21, pp185-188
20. Clinical predictors for delirium tremens in alcohol dependence. Lee, JH. Jang, MK, LEE, JY. Kim, SM. Kim, KH. Park, JY. Lee, JH. KIM, HY. YOO, JY. 2005, Journal of Gastroenterology and Hepatology, 20, pp. 1833-1837.
21. Clinical predictors of alcohol withdrawal delirium. Wetterling, T. Kanitz, R. Veltrup, C. Driessen, M. 1994, Alcoholism Clinical and Experimental Research, 18, pp. 1100-1102.
22. Rosenson, J. Clements, C, Simon, B. Vieaux, J. Graffman, S. Vahidnia, F, Cisse, B. Lam, J, Alter, H. Phenobarbital for acute alcohol withdrawal: a prospective randomized double-blind placebo-controlled study. 2013. The Journal of Emergency Medicine, 44, pp 592-598
23. Hjormo, I. Anderson, J. Fink Jensen, A. Allerup, P. Ulrichsen, J. Phenobarbital versus diazepam for delirium tremens: a retrospective study. 2010. Danish Medical Bulletin. 57
24. Crispo, A. Daley, M. Pepin, J. Harford, P. Brown, C. Comparison of clinical outcomes in nonintubated patients with severe alcohol withdrawal syndrome treated with continuous-infusion sedatives: dexmedetomidine versus benzodiazepines. 2014, Pharmacotherapy, 34,pp 910-917
25. Frazee, E. Personett, H Leung, J. Nelson, S. Dierkhising, R. Bauer,P. Influence of dexmedetomidine therapy on the management of severe alcohol withdrawal syndrome in critically ill patients. 2014. Journal of Critical Care,29, pp 298-302.
26. Wong, A, Benedict, N. Armahizer, M, Kane-Gill, S. Evaluation of adjunctive ketamine to benzodiazepines for management of alcohol withdrawal syndrome. 2015. Annals of Pharmacotherapy, 49, pp 14-19.
27. Sohraby R et al. Use of propofol-containing versus benzodiazepine regimens for alcohol withdrawal requiring mechanical ventilation. Ann Pharmacother. 2014;48:456-461.
28. Khan, L. Ahmed, J. Macfie, J. Refeeding syndrome: a literature review. 2010, Gastroenterology Research and Practice. 2011, pp 1-6
29. National Institute for Clinical Excellence. Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition. 2017
30. Wijdicks, E.Hepatic Encephalopathy. 2016. New England Journal of Medicine. 375, pp 1660-1670