ALCOHOL WITHDRAWAL GUIDELINES Policy author Accountable Executive Lead Approving body Policy reference Dr M Lewis, Gastroenterologist; Professor J A Vale, Clinical Toxicologist; Dr D A Robertson, Alcohol Lead. Clinical Director Emergency Care Governance Group for Medicine; Drugs & Therapeutics Committee SWBH/Gastro/09 ESSENTIAL READING FOR THE FOLLOWING STAFF GROUPS: 1 All Medical staff All Clinical staff STAFF GROUPS WHICH SHOULD BE AWARE OF THE POLICY FOR REFERENCE PURPOSES: 1 All Medical/Clinical staff POLICY APPROVAL DATE: June 01 POLICY IMPLEMENTATION DATE: June 01 DATE POLICY TO BE REVIEWED: June 018 Alcohol withdrawal guidelines Page 1 of 7
Version No Date Approved DOCUMENT CONTROL AND HISTORY Date of implementation Next Review Date Reason for change (e.g. full rewrite, amendment to reflect new legislation, updated flowchart, etc.) 4 January 009 January 009 January 011 December 011 December 011 December 014 June 01 June 01 June 018 To reflect new alcohol services, and reconfiguration of AMUs. Alcohol withdrawal guidelines Page of 7
1. INTRODUCTION Alcohol withdrawal syndrome is a common medical problem and follows the abrupt discontinuation of, or at least the rapid decrease in intake of, alcohol, the use of which has been heavy and prolonged. The syndrome usually begins within -8 hours of alcohol cessation or reduction, though alcohol withdrawal delirium does not usually develop for days after stopping drinking and usually lasts for at least 48 7 hours. For this reason a detailed alcohol history should be taken from all patients admitted to hospital. The alcohol withdrawal syndrome may develop in patients admitted to hospital for an unrelated illness (e.g. for an operation) or patients may present in a confused state or following an alcohol related seizure to the Emergency Department. In both these circumstances, which are medical emergencies, the diagnosis may be delayed, usually because it is not considered.. GENERAL POINTS The capacity of patients with alcohol intoxication or alcohol withdrawal should be assessed according to the Mental Capacity Act 00 (policy for assessing mental capacity (Pt Care/0). Patients who have capacity to make their own decisions may elect to discharge themselves. For further advice about assessing capacity, junior staff should first approach the senior members of their team and, if necessary, thereafter help can be obtained from the on-call psychiatrist. Contact security to help manage aggressive behaviour.. ASSESSMENT/TRIAGE Rapid triage is required to determine the severity of symptoms of alcohol withdrawal which should be assessed using the CIWA score (see attached form). Optimal management is determined by the patient s CIWA score, their commitment to alcohol cessation and their response to therapy (see Therapy Schedule). 4. EARLY SIGNS OF WITHDRAWAL (CIWA <8) Assuming that there are no other reasons for remaining in hospital, patients who show only early signs of withdrawal (CIWA <8) can be discharged and recommended to continue drinking alcohol. If such patients are keen to be considered for alcohol detoxification, they should be referred either for urgent out-patient review at City Hospital (typically within 1- weeks), prior to planned alcohol detoxification on the West Midlands Poisons Unit by telephoning 011 07 48 (Fax: 011 07 0), or for consideration of outpatient help withdrawing from alcohol, they can be referred to outpatient alcohol services (Swanswell at Sandwell; Reach Out Recovery at City).. WHERE SHOULD PATIENTS WITH ALCOHOL WITHDRAWAL SYNDROME BE MANAGED? If the patient s predominant clinical problem is alcohol withdrawal and the patient has a CIWA score >8, the patient should be discussed promptly by a member of the medical team with the Clinical Toxicologist on-call for the West Midlands Poisons Unit at City Hospital before treatment is commenced (Contact Switchboard for rota). If a patient is admitted with a diagnosis of alcohol withdrawal syndrome and is not referred on admission to the Clinical Toxicologist on call for the West Midlands Poisons Alcohol withdrawal guidelines Page of 7
Unit, subsequent transfer to the Poisons Unit will be a matter of consultant to consultant discussion. If a patient presents at Sandwell they should be discussed with the on-call Clinical Toxicologist as above (Contact Switchboard for rota). If the patient is unfit to be transferred to City Hospital advice should still be sought from the Clinical Toxicologist on-call for the West Midlands Poisons Unit. Consideration should be given to transferring the patient to Priory after referral to the Gastroenterology Team. In the rare instance where a patient at Sandwell with severe alcohol withdrawal is very difficult to manage, transfer to HDU should be considered, but this should only happen after discussion with the Sandwell consultant in charge of the patient s care.. THIAMINE SUPPLEMENTATION Alcohol dependent individuals are often thiamine deficient. Thiamine prevents Wernicke s encephalopathy and Korsakoff s psychosis and should therefore be administered to such patients on admission. If Korsakoff s psychosis or Wernicke s encephalopathy is suspected or considered likely to occur, parenteral administration of B vitamins is appropriate e.g. Pabrinex high potency injection intravenously over 10 minutes. In other cases, oral thiamine 100 mg b.d. should be given. Thiamine and vitamin B complex should be continued on discharge. 7. TREATMENT OF HALLUCINATIONS Patients presenting with alcohol withdrawal should be initially treated using diazepam. In patients who have had appropriate doses of diazepam in whom hallucinations remain a predominant feature of their alcohol withdrawal syndrome, an antipsychotic agent such as haloperidol. mg IM (maximum 1 mg daily) may be a useful adjunct. 8. ALCOHOL RELATED SEIZURES For patients presenting with a single fit resulting from alcohol withdrawal, inpatient detoxification is usually only indicated if they have other significant features of withdrawal (CIWA >8), when they should be referred immediately to the Clinical Toxicologist on-call for the West Midlands Poisons Unit at City Hospital (Contact Switchboard for rota). Routine CT head scans in such patients are unnecessary. It is important to consider early discharge of patients with alcohol related seizures if, on recovery from the seizure the CIWA score is <8, to prevent the development of more severe withdrawal. If the patient expresses a commitment to giving up alcohol and has a CIWA <8, the patient can be referred for outpatient review by Professor Vale or Dr Bradberry at City Hospital (typically within 1- weeks), by telephoning 011 07 48 (Fax: 011 07 0). 9. PLANNED ALCOHOL DETOXIFICATION WEST MIDLANDS POISONS UNIT Following out-patient assessment by Professor Vale and Dr Bradberry, patients committed to sobriety will be admitted to the West Midlands Poisons Unit for planned detoxification which takes some 7 hours in uncomplicated cases. The aims of detoxification are to: Provide safe withdrawal from alcohol to enable the patient to become alcohol free; Provide withdrawal that is humane, thus protecting the patient s dignity; Prepare the patient for an alcohol free existence. Alcohol withdrawal guidelines Page 4 of 7
Medical and nursing staff on the West Midlands Poisons Unit have substantial experience of managing alcohol withdrawal using a symptom-triggered regimen which is fully in accord with the NICE Guidelines (010). For patients unable/unwilling to come to City Hospital planned in-patient detoxification may be arranged with Dr Singhal, consultant gastroenterologist, on Priory. COMMUNITY ALCOHOL SERVICES Patients with no co-morbidities can be taken through alcohol detoxification in the community. Swanswell and Reach Out Recovery can provide this approach to appropriate individuals. Please contact them on discharge. 10. DISCHARGE Patients managed on the West Midlands Poisons Unit will be offered follow-up at the clinics of Professor Vale and Dr Bradberry. If the patient has not been managed on the West Midlands Poisons Unit, consider referral to Professor Vale or Dr Bradberry particularly if the patient is committed to giving up alcohol. For those not so committed, consider referral to the hospital-based representatives of the Community alcohol teams. Contact via switchboard. Consultant Clinical Toxicologists: Professor Vale, Dr Bradberry (Secretary: 011 07 48) Monday AM Clinic Alcohol providers: City contact: Phone: Reach Out Recovery: 011 7 890; Email: Birmingham.secure@cri.cjsm.net Sandwell contact: SPOC: 011 1 Email: support@swanswell.org.cjsm.net Alcohol withdrawal guidelines Page of 7
Appendix 1 West Midlands Poisons Unit: Alcohol Withdrawal Assessment Form [Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar)] Name DOB Hospital Number a) Nausea and vomiting 0 No nausea or vomiting 1 4 Intermittent nausea with dry heaves 7 Constant nausea, frequent dry heaves and vomiting b) Paroxysmal sweats 0 No sweats visible 1 Barely perceptible sweating, palms moist 4 Beads of sweat obvious on forehead 7 Drenching sweats c) Anxiety 0 No anxiety, at ease 1 4 Moderately anxious, guarded 7 Acute panic state, consistent with severe delirium or acute schizophrenia d) Agitation 0 Normal activity 1 Somewhat more than normal activity 4 Moderately fidgety and restless 7 Paces back and forth during most of the interview or constantly thrashes about e) Tremor 0 No tremor 1 Not visible, but can be felt at fingertips 4 Moderate when patient's hands extended 7 Severe, even with arms not extended f) Headache 0 Not present 1 Very mild Mild Moderate 4 Moderately severe Severe Very severe 7 Extremely severe g) Auditory disturbances 0 Not present 1 Very mild harshness or ability to frighten Mild harshness or ability to frighten Moderate harshness or ability to frighten 4 Moderately severe hallucinations Severe hallucination Extremely severe hallucinations 7 Continuous hallucinations h) Visual disturbances 0 Not present 1 Very mild photosensitivity Mild photosensitivity Moderate photosensitivity 4 Moderately severe visual hallucinations Severe visual hallucinations Extremely severe visual hallucinations 7 Continuous visual hallucinations i) Tactile disturbances 0 None 1 Very mild paraesthesias Mild paraesthesias Moderate paraesthesias 4 Moderately severe hallucinations Severe hallucinations Extremely severe hallucinations 7 Continuous hallucinations j) Orientation 0 Oriented and can do serial additions 1 Cannot do serial additions Disoriented for date by no more than calendar days Disoriented for date by more than calendar days 4 Disoriented for place and/or patient Date Time Score Total a b c d e f g h i j Heart Rate / BP Diazepam dose (route) Total score is a simple sum of each item score (maximum score is 7) <8 Mild withdrawal 8-1 Moderate withdrawal >1 Severe withdrawal Alcohol withdrawal guidelines Page of 7
Appendix Management of Alcohol Withdrawal Syndrome Perform CIWA-Ar Score. Refer urgently to Clinical Toxicologist on call (Contact Switchboard for rota) if CIWA >8 <8 8 1 >1 Consider discharge, but make out-patient referral to alcohol services. If there are other reasons for the patient to remain in hospital, repeat CIWA score in h. + h If CIWA <8 repeat CIWA score every h. Give diazepam 0-40 mg stat orally. Repeat CIWA score in 0 min while awaiting transfer of patient to AMU. Discuss with Clinical Toxicologist on call (via Switchboard) if concerns. + 0 min CIWA still 8 1, give diazepam another 0-40 mg stat orally. Repeat CIWA in 0min. + 0 min If a bed is still not available on the Poisons Unit (AMU-), and CIWA remains 8 1, discuss with Clinical Toxicologist. Give further diazepam as advised. Refer urgently to Clinical Toxicologist on call (Contact Switchboard for rota). While transfer to the Poisons Unit (AMU-) is being arranged, give diazepam 0 40 mg IV**. +1 min If CIWA >1, give diazepam 0 40 mg IV** every 1 minutes until CIWA is < 1 and transfer to the Poisons Unit (AMU-) or HDU as soon as bed available. Regular Medical Review is mandatory for all patients with a CIWA >8. **Intravenous diazepam should be given only if the SO can be monitored before and after administration and flumazenil is available. Ensure Clinical Toxicologist is aware of decision to give IV diazepam. If immediate concerns, seek ITU support. Alcohol withdrawal guidelines Page 7 of 7