MANAGING

ALCOHOL WITHDRAWAL
Prepared by J. Mabbutt & C. Maynard
NaMO
September 2008

7: Managing withdrawal
Objectives
1.

During the session nurses & midwives will learn how to identify,
assess & manage a patient in alcohol withdrawal

2.

By the end of the session nurses & midwives will have an

understanding or use of the AWS/CIWAR-Ar withdrawal scales

3.

At the end the session, nurses & midwives will have a basic
understanding & knowledge to safely & effectively identify, monitor
& manage alcohol withdrawal

7: Managing withdrawal

Effective management of withdrawal in its early stages can

reduce or prevent progression to complicated withdrawal

Complicated withdrawal may be life-threatening due to:

Accidental injury, dehydration, electrolyte imbalance, seizures,

delirium tremens, or the negative impact on other concurrent
disorders, including acute infection, renal disease or diabetes

7: Indications and guidelines:

Assessing withdrawal

Severe alcohol withdrawal is potentially life threatening

The most important thing is to anticipate when it may occur & to suspect
it when an unexplained acute organic brain syndrome is detected

Before continuing to assess alcohol withdrawal, the following information

focuses on a form of brain injury called the Wenickes-Korsakoff
syndrome

7: Indications and guidelines:

Complications of misuse
Wernicke-Korsakoff syndrome (1)

This is a form of brain injury resulting from thiamine deficiency, which

complicates alcohol dependence

If not treated early it can lead to permanent brain damage & memory loss
young alcohol-dependent people are at risk

Signs & symptoms of Wernickes encephalopathy, which is usually

the first stage of the syndrome, are:

Ophthalmoplegia (reduced eye movements or nystagmus)

Ataxia & confusion

7: Indications and guidelines:

Complications of misuse
Wernicke-Korsakoff syndrome (2)

This condition is reversible if recognised and treated with parenteral vitamin B1

Parenteral thiamine should be administered before any form of glucose

Glucose in the presence of thiamine deficiency risks precipitating

Wernickes encephalopathy

7: Indications and guidelines:

Assessing withdrawal Onset &
duration of alcohol withdrawal (1)

Onset of alcohol withdrawal is usually 6-24 hours after the last drink

Consumption of benzodiazepines or other sedatives may delay the onset of

withdrawal

In some severely dependent drinkers, simply reducing the level of consumption

may precipitate withdrawal, even if they have consumed alcohol recently

7: Indications and guidelines:

Assessing withdrawal Onset &
duration of alcohol withdrawal (2)

Usually withdrawal is brief & resolves after 2-3 days without treatment;
occasionally, withdrawal may continue for up to 10 days

Withdrawal can occur when the blood alcohol level is decreasing, even
if the patient is still intoxicated

Figure 9.1: Progress of alcohol withdrawal syndrome

7: Indications and guidelines:

Assessing withdrawal Index for
Suspicion of Alcohol withdrawal (1)

Severity of alcohol withdrawal ranges from mild to severe

The following questions, known as the Index for Suspicion of Alcohol

Withdrawal, will help you determine whether the patient is likely to
move into alcohol withdrawal:

A regular intake of 80 grams (8 drinks-Males) or 60 grams (6 drinks-Females)

of alcohol or more per day?

Taken even smaller amounts of alcohol in conjunction with other CNS

depressants?

Previous episodes of alcohol withdrawal?

7: Indications and guidelines:

Assessing withdrawal Index for
Suspicion of Alcohol withdrawal (2)

Current admission for an alcohol-related reason?

Physical appearance indicate chronic alcohol use:

parotid swelling (swelling in the gland under the ear)
cushingoid face (full/moon looking face)
facial telangiectasia (red spots/blood vessels)
eyes reddened or signs of liver disease
ascites, jaundice, limb muscle wasting

7: Indications and guidelines:

Assessing withdrawal Index for
Suspicion of Alcohol withdrawal (3)

Pathology results show raised serum GGT

Raised mean cell volume (MCV)

Displaying symptoms such as

anxiety,
agitation,
tremor,
sweatiness or early morning retching, which
might be due to an alcohol withdrawal syndrome?

7: Indications and guidelines: Signs

& symptoms of alcohol withdrawal (1)

Alcohol withdrawal is a syndrome of central nervous system hyperactivity

characterised by symptoms that range from mild to severe

The symptoms and signs of alcohol withdrawal may be grouped

into three major classes: See Table 9.4

Autonomic overactivity

Gastrointestinal

Cognitive & perceptual changes

Sweating

Anorexia

Anxiety

Tachycardia

Nausea

Vivid dreams

Hypertension

Vomiting

Illusions

Insomnia

Dyspepsia

Hallucinations

Tremor

Delirium

Fever
Table 9.4: Main signs & symptoms of alcohol withdrawal

7: Indications and guidelines: Signs

& symptoms of alcohol withdrawal (2)

Seizures occur in about 5% of patients withdrawing from alcohol

They occur early (usually 7-24 hours after the last drink), are grand mal
in type (i.e. generalised, not focal) & usually (though not always) occur
as a single episode

Delirium tremens (the DTs) is rare & is a diagnosis by exclusion

It is the most severe form of alcohol withdrawal syndrome, & a medical

emergency

7: Indications and guidelines: Signs

& symptoms of alcohol withdrawal (3)

DTs usually develops 2-5 days after stopping or significantly reducing

alcohol consumption

The usual course is 3 days, but can be up to 14 days

Its clinical features are:

Confusion & disorientation

Extreme agitation or restlessness the patient often requires restraining

7: Indications and guidelines: Signs

& symptoms of alcohol withdrawal (4)

Gross tremor

Autonomic instability (e.g. fluctuations in BP & pulse), disturbance

of fluid balance & electrolytes, hyperthermia

Paranoid ideation, typically of delusional intensity

Distractibility & accentuated response to external stimuli

Hallucinations affecting any of the senses, but typically visual

(highly coloured, animal form)

7: Indications and guidelines:

Alcohol withdrawal scales (1)

The most systematic & useful way to measure the severity of withdrawal
is to use a withdrawal scale

These provide a baseline against which changes in withdrawal severity

may be measured over time

Research shows that the use of scales minimises both under-dosing &
overdosing with benzodiazepines for alcohol withdrawal syndromes

7: Indications and guidelines:

Alcohol withdrawal scales (2)

There has been considerable debate about the application of withdrawal scales

Two different scales, the Alcohol Withdrawal Scale (AWS) and the Clinical
Institute Withdrawal Assessment for Alcohol (revised) (CIWA-Ar) are both are
recommended for use (see Appendices 2 and 3)

Being familiar with the alcohol withdrawal scale used in your local area is a
priority

7: Indications and guidelines:

Alcohol withdrawal scales (3)

Note that withdrawal scales do not diagnose withdrawal, but are merely
guides to the severity of an already diagnosed withdrawal syndrome

The nurse or midwife should re-evaluate the patient to ensure that it is

alcohol withdrawal & not another condition that is being measured,
particularly if the patient does not respond well to treatment

7: Alcohol withdrawal scales

Clinical Institute Withdrawal Assessment
for Alcohol Revised Version (CIWA-Ar) (1)

The CIWA-Ar (see Appendix 2) is a 10-item scale that can be administered

as part of supportive care

Several studies have shown that the CIWA-Ar scale is a valid, reliable &
sensitive instrument for assessing the clinical course of simple alcohol
withdrawal

7: Alcohol withdrawal scales

Clinical Institute Withdrawal Assessment
for Alcohol Revised Version (CIWA-Ar)
Videos

Video options show either of the following from the CIWA-Ar CD ROM

E5 Using the CIWA-Ar alcohol withdrawal scale (withdrawal symptoms are

demonstrated) (10.37 min)

E8 A Case study

7: Alcohol withdrawal scales

Clinical Institute Withdrawal Assessment
for Alcohol Revised Version (CIWA-Ar) (2)

This scale allows a quantitative rating (from 0 to 7 with a maximum

possible score of 67) of the following components of withdrawal:

Nausea & vomiting

Tremor

Paroxysmal sweats

Anxiety

7: Alcohol withdrawal scales

Clinical Institute Withdrawal Assessment
for Alcohol Revised Version (CIWA-Ar) (3)

Agitation

Tactile disturbances

Auditory disturbances

Visual disturbances

Headache and fullness in head

Orientation & clouding of sensoria

7: Alcohol withdrawal scales

Clinical Institute Withdrawal Assessment
for Alcohol Revised Version (CIWA-Ar) (4)
Using the CIWA-Ar in presentation to the emergency department:

Monitor the patient hourly for at least 4 hours using the CIWA-Ar

Contact the medical officer or drug & alcohol nurse practitioner for assessment
and monitor hourly if:
the alcohol score increases by at least 5 points over this 4-hour period, or
the CIWA-Ar total score reaches 10

7: Alcohol withdrawal scales

Clinical Institute Withdrawal Assessment
for Alcohol Revised Version (CIWA-Ar) (5)
Using the CIWA-Ar for hospitalised patients:

Monitor the patient 4-hourly, using the CIWA-AR, for at least 3 days

If the total score reaches 10, monitor hourly & notify the medical officer
or drug & alcohol nurse practitioner

7: Alcohol withdrawal scales

Alcohol withdrawal scale (AWS) (1)
Alcohol Withdrawal Scale (AWS)

The AWS (see Appendix 3) is a widely used scale in NSW

If a patients history or presentation suggests possible withdrawal,

the patients condition must be monitored & documented

7: Alcohol withdrawal scales

Alcohol withdrawal scale (AWS) (2)

The AWS (see Appendix 3) is a widely used scale in NSW and is a 7 item
scale that allows a quantitative rating (from 0 to 4) of the following components:

Perspiration

Tremor

Anxiety

Agitation

Axilla temperature

Hallucinations

Orientation

7: Alcohol withdrawal scales

Alcohol withdrawal scale (AWS) (3)
Using the AWS in presentation to the emergency department:

Monitor the patient hourly for at least 4 hours using the AWS

Contact the medical officer or drug & alcohol nurse practitioner for assessment
& monitor hourly if:
the alcohol score increases by at least 5 points over this 4-hour period, or
the AWS total score reaches 5

7: Alcohol withdrawal scales

Alcohol withdrawal scale (AWS) (4)
Using the AWS for hospitalised patients:

Monitor the patient 4-hourly, using the AWS, for at least 3 days

If the total score reaches 5, monitor hourly & notify the medical officer
or drug & alcohol nurse practitioner

Depending on the resources of the local area, these may need review

7: Indications and guidelines:

Pharmacological Treatment (1)
From NSW Drug & Alcohol Withdrawal Clinical Practice Guidelines
NSW Health 2007

The most commonly prescribed pharmacological treatment for alcohol

withdrawal is diazepam because of its cross-tolerance with alcohol &
anti-convulsant properties

Two types of regimes for specialist residential or inpatient setting

Diazepam loading regime

Symptom-triggered sedation

7: Indications and guidelines:

Pharmacological Treatment (2)
Diazepam loading regime

On the development of withdrawal symptoms initiate diazepam loading

20mg initially, increasing to 80mg over 4-6 hours

Or until pt is sedated

Medial review required if dose exceeds 80mg & more diazepam can
be ordered depending on withdrawal condition

7: Indications and guidelines:

Pharmacological Treatment (3)
Symptom-triggered sedation

Mild withdrawal CIWA-AR <10 & AWS <4

Supportive care, observations 4 hourly

If sedation necessary; 5-10mg oral diazepam every 6-8 hours for first 48 hrs

7: Indications and guidelines:

Pharmacological Treatment (4)
Symptom-triggered sedation

Moderate withdrawal CIWA-AR 10-20 & AWS <5-14

Medical officer to assess

If alcohol withdrawal confirmed: hourly observations; give 10-20 oral

diazepam immediately; repeat 10mg hourly or 10-20mg 2hrly until the
pt achieves good symptom control (up to a total dose of 80mg)

Repeat medical review after 80mg of diazepam and if pt is not

settling, consider olanzepine (zyprexia) 5-10mg

7: Indications and guidelines:

Pharmacological Treatment (5)
Symptom-triggered sedation

Severe withdrawal CIWA-AR 20+ & AWS 14+

Urgent management. Give a loading dose

Review more frequently until score falls

A rising score indicates a need for more aggressive management

7: Indications and guidelines:

Pharmacological Treatment (6)

Contraindications to diazepam include:

respiratory failure,
significant liver impairment,
possible head injury or cerebrovascular accident in these situations,
specialist consultation is essential
From NSW Drug and Alcohol Withdrawal Clinical Practice
Guidelines NSW Health 2007
http://www.health.nsw.gov.au/policies/gl/2008/GL2008_011.html