CASE PRESENTATION ON
ALCOHOL WITHDRAWAL DELIRIUM
PATIENT PROFILE FORM
Weight : 55kgs
Reasons for admission:
severe manifestation of alcohol withdrawal,
which occurs 5 days following the last drink
these symptoms are observed Hallucinations,
shortness of breath, delusions, irrelevant talk,
Past medical history:
history of habitual alcohol use or alcoholism
that has existed for more than 6 years.
Past Medication history:
Pastly his father also chronic alcoholic, his
father died with life threatening seizures and
using tranquilizer drugs of the barbiturate or
benzodiazepines strong addiction to them.
what is alcohol withdrawal delirium(awd) and causes of
Alcohol Withdrawal Delirium:
Alcohol withdrawal delirium (AWD) is the most serious form of alcohol
withdrawal. It causes sudden and severe problems in brain and nervous
Approximately five percent of hospital patients being treated for alcohol
withdrawal also experience AWD. AWD is also known as delirium tremens
or DTs. It is a medical emergency
Delirium tremens (also referred to as The DTs, "the horrors", "the bottle
ache", "quart mania", "ork orks", "gallon distemper", "barrel fever", or "the
shakes") is an acute episode of delirium that is usually caused by
withdrawal from alcohol
Causes of Alcohol Withdrawal Delirium: AWD only affects people with a
history of heavy alcohol use. Heavy drinkers may develop this condition if
they:suddenly stop drinking ,reduce their alcohol use too quickly,don’t eat
enough when reducing alcohol use, head injury, another cause of delirium
tremens is abrupt cessation of tranquilizer drugs of the barbiturate or
benzodiazepine classes in a patient with a relatively strong addiction to
It is a neuropsychiatric syndrome also called
acute confusional state or acute brain failure
that is common among the medically ill and
often is misdiagnosed as a psychiatric illness
which can result in delay of appropriate
medical intervention. There is significantly
mortality associated with delirium so
identifying it is crucial
Pharmaceutical care plan:
severe manifestation of alcohol withdrawal, which occurs 5 days following
the last drink these symptoms are observed Hallucinations, shortness of
breath, delusions, irrelevant talk, sleeplessness.
doctor will perform a physical exam to see if have AWD symptoms.
Based on scales CIWA- Ar scale (The Clinical Institute Withdrawal
Assessment for alcohol scale) is used widely as a means to gauge the
severity of alcohol withdrawal).
doctor suggests Some tests that may be needed for a diagnosis include:
take a breath analyzer reading –indicates where patient is in the withdrawal
Using a nonalcoholic skin preparation, draw blood for measurement of
ethanol concentration, toxicology screen for other drugs of abuse.
blood tests to measure magnesium and phosphate
based on subjective and objective evidence of physical examination and
patient social history the diagnosis was made as ―Alcohol Withdrawal
Goals to be achieved
To Save the patient life.
To Relieve the signs and symptoms.
if hospital stay is needed. The health care team will regularly
To Avoid or reduce the use of alcohol. Get prompt medical
treatment for symptoms of alcohol withdrawal.
To Prevent further possible complications like
Injury from falls during seizures
Injury to self or others caused by mental state
Irregular heartbeat, may be life threatening
alcoholic liver disease
alcoholic neuropathy (nerve damage caused by alcohol use)
alcoholic cardiomyopathy (weak heart muscle due to alcohol
Wernicke-Korsakoff syndrome (brain damage from a lack of
diazepam or lorazepam,
chlordiazepoxide (Librium) or oxazepam
temazepam (Restoril) or midazolam (Versed)
B.P :140/90 mm Hg
On first day patient is not sleeping well, irrelevant talk, night mares
Advised to antipsychotic drugs . special precaution to be taken for
tab.librium i.e. 2tabs till patient sleep later 4th hourly ,skip a dose if
patient is a sleep
Normal body temperature and blood pressure.
Hearing disturbances occurring in the patient.
On the second day doctor suggest a
precaution for tab.librium i.e. 2tabs 6th hourly
,skip a dose if patient is a sleep.
DRUG CHART :
DRUGS Dose Rout
DAY-2 DAY-3 DAY-4
Tab.librium 25mg oral 0D D D D D
1amp I.M B.D D D D D
5mg oral O.D D D D D
2mg oral B.D D D D D
+ I.m SOS D D ------ -------
Blood pressure is normal
Advised to stop injection haloperidol +
Patient is drowsy
Pulse rate: 80 beats/min
Doctor advised to discharge for the patient in
better relevant talk ,no psychotic features
Reduction of sleeping disturbances and
patient is sleeping well after taking the
Patient Talking Relevantly by 2nd day.
Patient feels better on 3rd day.
Monitor thorough examination for signs of autonomic hyperreactivity i.e,
tachycardia,diaphoresis,elevated body temperature,dilated but reactive
Be aware that people tend to underestimate drinking habits.
Observe behavior for talkativeness,restlessness,agitation,preoccupation.
monitoring of electrolytes and vital signs every 30 minutes.
Place the patient in a private room for close observation.
To assess respiratory,hepatic, and cardiovascular status of patient ---
pneumonia, liver disease, and cardiac failure are complications.
To observe for hypoglycemia and treat appropriately.hypoglycemia may
accompany alcoholic withdrawal because alcohol depletes liver glycogen
stores and impairs gluconeogenesis—many patients also suffer from
To monitor electrocardiogram (ECG) to check heart function
To monitor electroencephalogram (EEG) to record the electrical
activity in brain
If problem drinking is identified early, it may
mean that complications, including severe
alcohol withdrawal and delirium tremens, are
In this patient electrolyte balance should not
The interaction of alcohol with the CYP-450 enzyme system can be
complex and depends upon the duration of alcohol consumption. (34)
Short-term consumption leads to a competitive inhibition of the
CYP2E1 enzyme, whereas chronic use leads to its induction. CYP2E1
induction leads to an increased clearance of drugs such as warfarin,
diazepam, rifamycin, meprobamate, pentobarbital, propranolol, and
alcohol itself, with the effect upon liver metabolism lasting for days to
weeks after the discontinuation of alcohol.
the CYP2E1 enzyme system converts otherwise safe substances into
highly toxic metabolites. These include industrial solvents, cocaine,
some anesthetic agents (e.g., enflurane, methoxyflurane), isoniazid,
phenylbutazone, and acetaminophen. Through the induction of this
alternate pathway of drug metabolism, ordinarily innocuous doses of
these agents may become hepatotoxic.
The combination of benzodiazepines and alcohol can amplify the
adverse psychological effects of each other causing enhanced
depressive effects on mood and increase suicidal actions and are
generally contraindicated except for alcohol withdrawal
Cognitive behavioral therapy and
motivational enhancement therapy (which are
sometimes combined with pharmacologic therapy)
have been used successfully to prevent relapse.
Alcohol cessation programs and support groups,
such as Alcoholics Anonymous, should be
Computer-based screening and counseling
programs may be useful when clinicians do not
have time to perform screening and face-to-face
Antipsychotics - Phenothiazines and butyrophenones lower the seizure
threshold. They should be used with extreme caution in the withdrawing
alcoholic. These agents may also interfere with heat dissipation and,
perhaps most importantly, do not exhibit cross-tolerance with alcohol thus
their efficacy is suspect.
Antiepileptic: There is some interest in the use of anti-epileptics for the
treatment of acute alcohol withdrawal. In initial studies carbamazepine, an
anticonvulsant agent widely used in Europe for alcohol withdrawal
syndrome, was shown to decrease the severity of withdrawal symptoms
comparable to the benzodiazepines in terms of adverse events, and was
equally as effective as lorazepam in decreasing the symptoms of alcohol
withdrawal. (21-23 ciwa-ar) However, a subsequent systemic review of a
heterogeneous group of trials was unable to draw definite conclusions
based on the variable study designs employed and the low overall mortality
rates observed. (24) Hence, there is not a large enough body of evidence
to suggest using carbamazepine in acute alcohol withdrawal.
The vitamins of most importance in alcohol withdrawal are thiamine and
folic acid. To help to prevent Wernicke syndrome alcoholics should be
administered a multivitamin preparation with sufficient quantities of thiamine
and folic acid.