Dr. Sumit Chandak discusses the management of alcohol withdrawal, including identifying at-risk patients, assessing severity, and treating complications. Key points include using the CAGE questionnaire to screen for problem drinking, monitoring for withdrawal symptoms using the CIWA-Ar scale, and managing complications like delirium pharmacologically with benzodiazepines while also employing environmental interventions and frequent reorientation. The goal is to promote abstinence and safely manage withdrawal to prevent associated increased morbidity.

1. Dr SumitChandak
Asst. Prof, Department of Psychiatry
SKNMC & GH
Management of Alcohol Withdrawal

2. Objectives:
 Identifying an at risk patient.
 Assessment for severity of withdrawal in at risk
patient.
 Complication’s of alcohol withdrawal and their
assessment.
 Management of alcohol withdrawal and its
complications.

3. Identify at risk individuals:-
 Need to identify at risk individuals:-
Low detection rates
High rates of Mx/Sx complications when undetected

4. Identifying an at risk patient :
Elicit: History of alcohol/ substance use in all patients.
Ask → Pattern of use
Duration of use
Quantity of use
Time since last drink
May not be possible when → acutely intoxicated
acute trauma
Then ask :– friends
family members
Look for:- Smell of alcohol in the breath
Features of withdrawal
– Tremors
–
Tachycardia
-↑BP
Obtain blood alcohol level- if possible

5. To identify potential problem drinkers:
Use screening tool: CAGE questionnaire.
 C: Have you ever felt you should cut down on your
drinking?
 A: Have people annoyed you by criticizing your
drinking ?
 G: Have you ever felt bad or guilty about your
drinking ?
 E: Have you ever had a drink first thing in the morning
to steady your nerves or get rid of a hangover (eye
opener)?

6. Assessment in at risk patient:
Primarily for:
 factors predisposing to complications
 severity of withdrawal

7. Assessment for predisposing
factors:
Metabolic disturbances: Hypoglycemia
Lactic acidosis
Ketoacidosis
↓Na, Ca2+,Mg²
↓ed /↑ ed K.
↑ed Triglycerides
Cardiac problems : most common
Serious post op problems sec to:
↑ Risk of CAD
↑ed cardiovascular stress sec to
withdrawal
G.I. problems: PUD
Hepatitis
Hematological monitoring:
As alcohol suppresses bone marrow
Presence of neurological factors

8. For severity of withdrawal :
 Clinical monitoring – intensively for first few days.
 For s/s of alcohol withdrawal
 Sx population : can use scales like CIWA-AI

9. CIWA-Ar Clinical Institute withdrawal
assessment of Alcohol scale , revised
 Observation on 10 parameters.
Nausea and
vomiting
Tactile
disturbances
Tremor
Auditory
disturbance
Paroxysmal
sweats.
Visual
disturbances
Anxiety

10. CIWA-Ar Clinical Institute
withdrawal assessment of Alcohol
scale , revised
 Scores max possible: 67
 Interpretation 6-7 mild withdrawal
8-14 : moderate withdrawal
>15: severe withdrawal

11. Complication of withdrawal state:
Delirium: can occur anytime within 7days
Seizures: usually around 3 day of last drink
Other : Wernickes encephalopathy
Psychosis
Depression

12. Delirium
Definition: The hallmark symptom of delirium is an
impairment of consciousness, usually
accompanied by global impairments of cognitive
functions; generally associated with emotional
labiality, hallucinations or illusions, and
inappropriate, impulsive, irrational, or violent
behavior.
 Generally considered to be an acute reversible
disorder but can become irreversible.

13. Delirium
 Diagnostic criteria:
A] Disturbance of consciousness (i.e. reduced clarity
of awareness of the environment) with reduced
ability to focus, sustain, or shift attention.
B] A change in cognition (such as memory deficit ,
disorientation, language disturbance) or the
development of a perceptual disturbance that is not
better accounted for by a preexisting, established,
or evolving dementia
.

14. Delirium:
 Diagnostic criteria:
C] The disturbance develops over a short period of time
(usually hours to days) and tends to fluctuate during
the course of the day.
D] There is evidence from the history, physical
examination, or laboratory findings of either (1) or (2):
1] The symptoms in Criteria A and B developed during
substance intoxication.
2] Medication use is etiologically related to the
disturbance.

15. Delirium
Assessment:
 Points to remember: fluctuating orientation
Sequence of disorientation: T->PL->PE
Sequence of re-orientation: PE->PL->T
 ASK for TIME: time/day/date/month/year
PLACE: where are you/On what floor
PERSON: Check for recognition of
relatives/confabulation
 Cross check data with relative/attendant

16. Management of alcohol withdrawal /
risk patient:
 In at risk patient promote abstinence for at least 4
weeks of an elective pre-op procedure as it
decreases morbidity from 74% -31%
 Modalities of Intervention:
1]Pharmacotherapy : Substitute
Adjuvant
2] Counseling

17. Pharmacotherapy:
Substituent : Act on GABA receptors & mimic the
action of
alcohol:
Lorazepam :po│im│iv
Librium : po only
 Dosing depends on : severity of withdrawal
presence of hepatic
dysfunction
altered neurological
states
 1st 24 hours: fixed dosing schedule
flexible dosing schedule

18. Pharmacotherapy
 Fixed dosing :Depending on the Quantity, Quality
of alcohol and the time of last drink consumed.
For Ex:
Librium (10/25): 1-1-2
0-1-2
0-0-2
Lopez (2) : 2-2-2
1-1-2
 Caution: Monitor Respiratory Rate

19. Pharmacotherapy:
 Flexible dosing admission monitor for—s/s of
withdrawal :
IF PRESENT: IF ABSENT:
If present
↓
Give Librium (10) 2 stat
↓
Monitor 2 hourly
↓
If increased F/O withdrawal
↓
If decreased
↓
Continued monitoring 2
hourly
If absent
↓
Monitor 4 hourly
↓
If present

20. Pharmacotherapy
 Dose obtained at end of 24hours is the total dose
required by that individual
 Continue on the same dose for 48 hours.
 Then taper by 20% every day every day, till
eliminated.

21. Pharmacotherapy:
Adjuvant :For symptomatic control:
1] Propranolol
2]CBZ
For metabolic parameters :
 Plenty of oral fluids
 Injection Thiamine/MVBC before any I.V. fluids
especially containing sugar
 Tb Thiamine 75/100mg bid

22. M/M of Delirium :
 Rule out other causes
 Lab: Se Electrolytes, BSL, LFT, RFT
SOS: EEG
 M/M:
 Pharmacotherapy as above
 Restrain the patient
 Keep the lights on at night
 Frequently talk to & reorient the patients
 Correct electrolyte imbalance and underlying
hepatic d/o if any
 When protracted - ECT

23. THANK YOU

24. DO’S FOR DELIRIUM:
 Employ environmental interventions to reduce
factors that may
exacerbate delirium.
These interventions include
• changing the lighting to cue day and night,
• reducing monotony and overstimulation and
understimulation,
• correcting visual and auditory impairments (e.g.,
retrieve glasses,
hearing aids), and
• rendering the patient’s environment less alien by
having familiar
people and objects present (e.g., family photographs).

25. DO’S FOR DELIRIUM
 Reorient the patient to person, place, time, and
circumstances.
 Reorientation should be provided by all who
come into contact with the patient.
 Provide reassurance to patients that the deficits
they are experiencing are common but usually
temporary and reversible.

26. DONT’S FOR DELIRIUM
 Unnecessarily restrain the patient
 Avoid Anticholinergics drugs like Phenergan in
delirium especially alcohol withdrawal