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Level 2 of 6Must-remember

Alcohol intoxication and withdrawal

Assess, manage and stay safe — enough on its own

The card — assess, manage, caution

Assessment— look, ask, measure

  • Check the capillary glucose first, in every patient, and repeat it hourly while consciousness is impaired: hypoglycaemia is common, recurrent and lethal, a normal value now does not exclude a later fall, and in children profound hypoglycaemia rather than sedation is the killer.
  • Treat 'drunk' as a diagnosis of exclusion: every obtunded patient who smells of alcohol needs a glucose, a core temperature, a pupil examination, a scalp survey and an explicit decision about imaging — alcohol intoxication should be a diagnosis of exclusion for altered mental status and coma.
  • Ask when the last drink was, not when the patient arrived: withdrawal is timed from the last drink — minor withdrawal at 6–12 hours, alcoholic hallucinosis at 12–24 hours, withdrawal seizures at 6–48 hours, and delirium tremens at 1–3 days, which is why delirium tremens is commonly seen 1–2 days after admission.
  • Ask how much and how regularly: a unit contains about 8 g of absolute alcohol and raises the blood alcohol concentration by 15–20 mg/dL; low-risk drinking is 14 units per week for both sexes, and recent weekly intake greater than 100 units predicts complicated withdrawal.
  • Track the trajectory of consciousness: an intoxicated patient should get progressively better, so one unchanged or worse at two hours, or whose GCS falls by two points, needs urgent CT.Not available at your setup — CT scan.
  • Use the dose–effect table to detect mismatch: 20–99 mg/dL impaired coordination and euphoria; 100–199 ataxia and poor judgement; 200–299 marked ataxia, slurred speech, nausea and vomiting; 300–399 stage 1 anaesthesia and memory lapse; 400 mg/dL and above respiratory failure, coma and death.
  • Interpret the mismatch: a patient more obtunded than the drinking history explains has a second diagnosis, and one less obtunded than a very high measured level is tolerant and will withdraw — a tolerant drinker may walk and converse at 300 mg/dL while a naive adolescent may be comatose at 200 mg/dL.
  • Examine for intoxication: conjunctival injection, nystagmus, dysarthria, ataxic gait, labile affect and vomiting, and with deeper intoxication hypoventilation, hypothermia and loss of airway reflexes.
  • Diagnose withdrawal on any three of: tremor of the outstretched hands, tongue or eyelids; sweating; nausea or vomiting; tachycardia or hypertension; anxiety; psychomotor agitation; headache; insomnia; malaise; transient visual, tactile or auditory hallucinations; and grand mal convulsions.
  • Separate alcoholic hallucinosis from delirium tremens by orientation and attention, not by the presence of hallucinations: in hallucinosis the sensorium is clear and the patient orientated, whereas in delirium tremens the patient is disorientated and agitated with coarse tremor, visual hallucinations of insects or small animals, sweating, tachycardia, tachypnoea and pyrexia.
  • Look for Wernicke's encephalopathy in every confused drinker: confusion, impaired eye movements and gait ataxia are the hallmarks, but only about one-third present with the classic triad and most are profoundly disorientated, indifferent and inattentive — horizontal nystagmus on lateral gaze, lateral rectus palsy (usually bilateral) and conjugate gaze palsies are the ocular signs.
  • Score withdrawal with CIWA-Ar — ten domains (nausea and vomiting; tremor; paroxysmal sweats; anxiety; agitation; tactile, auditory and visual disturbances; headache; and orientation and clouding of sensorium) to a maximum of 67: below 8 minimal, 8–15 moderate, above 15 severe.
  • Know when CIWA-Ar is unusable: it is a symptom scale, invalid in anyone who cannot communicate or be assessed reliably (intubated, sedated, language barrier, dementia, delirium of another cause, head injury), and non-specific — pain, sepsis, hypoxia, opioid withdrawal and a full bladder all raise it; where it is unusable, rising pulse and blood pressure 12 hours after the last drink represent withdrawal until proved otherwise.
  • Hunt the red flags that mean a second diagnosis: coma or GCS 8 or less, absent gag or a falling GCS; any lateralising sign, unequal pupils, scalp haematoma or laceration; fever, neck stiffness or hypotension; haematemesis or melaena; Kussmaul breathing or high-anion-gap acidosis; visual disturbance or snowstorm blindness suggesting methanol; and an escalating benzodiazepine requirement marking evolving delirium tremens.Not available at your setup — Arterial blood gas.
  • Identify the patient at risk of complicated withdrawal before it starts: previous withdrawal seizures; previous severe or complicated withdrawal or delirium tremens; recent weekly intake greater than 100 units; significant withdrawal symptoms already evident; and communication difficulties that make reliable scoring impossible — with older age, intercurrent infection, recent trauma or surgery and decompensated liver disease adding further risk.
  • In children, expect a different disease: the two presentations are accidental ingestion in a toddler (drinks left after a party, mouthwash, perfume, hand sanitiser) and the adolescent binge drinker brought in unconscious or vomiting; children desaturate faster so the interval between sleepy and obstructed is short, physical dependence and withdrawal are essentially not seen before puberty, and a seizure in an intoxicated child is hypoglycaemia or trauma until proved otherwise.

Management— do this, in order

  • Position and protect the airway first, because airway compromise, not alcohol, kills the intoxicated patient: nurse the obtunded unintubated patient in the left lateral (recovery) position with suction available, never supine and never unobserved; a nasopharyngeal airway is often better tolerated than an oropharyngeal one but is avoided if base-of-skull fracture is suspected, and definitive airway protection is required for GCS 8 or less, absent gag or repeated vomiting.Doctor / NurseNot available at your setup — Endotracheal intubation kit.
  • Give thiamine before any glucose-containing solution: glucose infusion consumes residual thiamine and may precipitate Wernicke's disease in a previously unaffected patient or rapidly worsen an early form.Doctor / Nurse
  • Treat documented symptomatic hypoglycaemia immediately even so — hypoglycaemic brain injury occurs in minutes, the thiamine–glucose interaction over hours: give 25% glucose 100 mL (or 50% glucose 50 mL) by slow intravenous injection into a large well-running cannula, followed by a 10% glucose infusion because a single bolus will not hold in a glycogen-depleted patient; recheck at 10 minutes, then hourly.Doctor / NurseNot available at your setup — Infusion pump.
  • In children give 10% glucose 2 mL/kg then a 10% infusion at maintenance rate; concentrated 50% glucose must not be given to small children, being hyperosmolar and sclerosant.Doctor / NurseNot available at your setup — Infusion pump.
  • Thiamine for suspected or possible Wernicke's (any confusion, eye sign or ataxia; coma; delirium tremens): 500 mg intravenously three times daily for 2–3 days, then 250 mg intravenously or intramuscularly daily for 5 days with other B vitamins, then oral thiamine 100 mg daily while at risk; parenteral doses are diluted in 50–100 mL of 0.9% sodium chloride or 5% glucose and infused over about 30 minutes, and deep intramuscular injection is acceptable without venous access.Doctor / Nurse
  • Thiamine prophylaxis in any dependent or malnourished drinker: 250 mg parenterally daily, slowly, for 3–5 days, then oral thiamine 100 mg three times daily (or 300 mg daily) while risk persists; paediatric dose is 25–50 mg intravenously or intramuscularly daily in a younger child, adult dosing in an adolescent of adult size.Doctor / Nurse
  • Fluids and supportive care in intoxication: correct dehydration with 0.9% sodium chloride, keep the patient warm, and investigate hypotension actively — haemorrhage, sepsis, pancreatitis, ketoacidosis, hypothermia — since it is never attributable to alcohol alone.Doctor / Nurse
  • Vomiting: manage by position and suction, with ondansetron 4–8 mg by slow intravenous injection (children 0.1–0.15 mg/kg, maximum 4 mg) or metoclopramide 10 mg intravenously, the latter avoided in the young because of dystonic reactions.Doctor / Nurse
  • Agitation in a patient who is intoxicated rather than withdrawing is managed by de-escalation, a safe environment and correction of reversible contributors (hypoxia, hypoglycaemia, pain, a full bladder) — adding a benzodiazepine to a high blood alcohol level risks the very respiratory depression one is trying to avoid.
  • Benzodiazepines are the treatment of withdrawal and the only class shown to reduce both withdrawal seizures and delirium; under-treatment is the commoner and more dangerous error.
  • Symptom-triggered dosing where the patient can be scored: score with CIWA-Ar hourly and at 8 or above give a single dose of chlordiazepoxide 20–30 mg orally, diazepam 10 mg orally, or lorazepam 1–2 mg orally in liver disease or the elderly; rescore in an hour and repeat while the score remains 8 or above, and once the score has been below 8 for eight hours scoring may fall to four-hourly.
  • Before every dose confirm the patient is rousable, the respiratory rate 12 or more, and there is no new focal neurology.
  • Fixed-dose reducing regimen where the patient cannot be scored: chlordiazepoxide 20–30 mg orally four times daily on day 1, 15–20 mg four times daily on day 2, 10–15 mg four times daily on day 3, 10 mg four times daily on day 4 and 10 mg twice daily on day 5, then stop, with an as-required dose for breakthrough; reduce doses by a third to a half and lengthen intervals in the elderly, the frail and those with respiratory or hepatic impairment, or change to lorazepam.
  • Where the oral route is unavailable: diazepam 10 mg by slow intravenous injection at no more than 5 mg per minute, or lorazepam 2 mg intravenously or intramuscularly, always with monitoring, oxygen, suction and a bag-valve-mask available — lorazepam is the only agent reliably absorbed intramuscularly and diazepam must never be given intramuscularly.Doctor / Nurse
  • A withdrawal seizure: protect the head, place the patient left lateral, give oxygen, suction the airway and check the capillary glucose during the seizure; if it exceeds five minutes or a second occurs without recovery between, give lorazepam 4 mg intravenously over 2 minutes (repeatable once after 10 minutes), diazepam 10 mg intravenously at no more than 5 mg per minute, or — without access — midazolam 10 mg buccally or intramuscularly.Doctor / Nurse
  • Paediatric seizure doses: lorazepam 0.1 mg/kg intravenously (maximum 4 mg), diazepam 0.1–0.3 mg/kg intravenously (maximum 10 mg) or 0.5 mg/kg rectally, or midazolam 0.3 mg/kg buccally (maximum 10 mg).Doctor / Nurse
  • Delirium tremens needs intravenous benzodiazepine titrated to effect in doses substantially larger than in ordinary withdrawal: front-load with diazepam 10 mg by slow intravenous injection over at least two minutes, repeated every 5–10 minutes until the endpoint, or — in significant liver disease or the elderly — lorazepam 2–4 mg intravenously every 10–15 minutes; the endpoint is light sleep from which the patient rouses to voice, not unconsciousness and not a fixed cumulative dose.Doctor / Nurse
  • Support the patient in delirium tremens as hard as you sedate them: 0.9% sodium chloride titrated to pulse, blood pressure and hourly urine output; active treatment of hyperthermia, which is a genuine cause of death; hourly glucose; magnesium sulfate 2 g (8 mmol) intravenously in 100 mL of 0.9% sodium chloride over 20–30 minutes where the level is low or tremor persists despite normal potassium; and high-dose parenteral thiamine for every patient, all of whom are presumed at risk of Wernicke's encephalopathy.Doctor / NurseNot available at your setup — Infusion pump, Serum electrolytes.

Caution— what harms

  • Never attribute obtundation to alcohol without excluding the alternatives: patients with altered mental status require evaluation to exclude head trauma, infection or hypoxia, and subdural haematoma follows unwitnessed falls and may leave no external mark.Not available at your setup — CT scan.
  • Never give glucose before thiamine in a dependent or malnourished drinker — the one qualification being documented symptomatic hypoglycaemia, which is treated immediately.Doctor / Nurse
  • Oral thiamine is not adequate for suspected Wernicke's, absorption in a chronic drinker being unreliable; anaphylaxis to parenteral thiamine is rare but real and is never a reason to withhold it, and replacement may fail until hypomagnesaemia is corrected because thiamine-dependent enzymes need magnesium as cofactor.Doctor / NurseNot available at your setup — Serum electrolytes.
  • Never give concentrated 50% glucose to a small child — it is hyperosmolar and sclerosant; use 10% glucose 2 mL/kg.Doctor / Nurse
  • Flumazenil has no role: in a benzodiazepine-tolerant patient it may precipitate seizures that benzodiazepines can no longer control.Doctor / Nurse
  • Never give diazepam intramuscularly — absorption is erratic; and remember that chlordiazepoxide and diazepam accumulate in hepatic impairment, so choose lorazepam in liver disease, the elderly and respiratory compromise.Doctor / NurseNot available at your setup — Liver function tests.
  • Phenytoin neither prevents nor treats alcohol withdrawal seizures, and a long-term anticonvulsant is not indicated after an uncomplicated one; terminating the fit is not the treatment, because a single dose followed by nothing is how the next seizure occurs.Doctor / Nurse
  • Antipsychotics are adjuncts only, never a substitute for benzodiazepines: they lower the seizure threshold, prolong the QT interval and do not prevent seizures or death — where one is needed, haloperidol 2.5–5 mg intramuscularly or by slow intravenous injection (0.5–1 mg in the elderly), repeated after 30–60 minutes if necessary and with an ECG, is conventional.Doctor / Nurse
  • Beta-blockers and clonidine mask the parameters used to titrate treatment and must never be monotherapy; alcohol itself is not a treatment.Doctor / Nurse
  • In delirium tremens, under-dosing is the commoner and more dangerous error — titrate to light rousable sleep, hold the patient there with regular and as-required doses rather than allowing swings back into agitation, and remember that every dose carries an airway consequence, so titration requires continuous monitoring, oxygen and suction.Doctor / Nurse
  • Fever is never attributed to withdrawal or delirium tremens without a septic screen — cultures, a chest radiograph and, where ascites is present, a diagnostic tap; aspiration pneumonia is often clinically silent.Not available at your setup — Blood culture, Ultrasound.
  • Do not use CIWA-Ar in a patient who cannot be scored: symptom-triggered dosing is unsafe there and a fixed-dose regimen with clinical review is used instead.
  • Correct hyponatraemia slowly: malnourished chronic drinkers are the classic population for osmotic demyelination, and correction should not exceed approximately 8 mmol/L in 24 hours and 15 mmol/L in 48 hours.Not available at your setup — Serum electrolytes.
  • Do not escalate ineffective boluses outside a monitored environment — a patient whose benzodiazepine requirement escalates has benzodiazepine-resistant withdrawal, which needs the differential reopened (CT head, meningitis, hepatic encephalopathy, Wernicke's, sepsis, hyponatraemia, non-convulsive status) and a different drug class with airway support available.Doctor / NurseNot available at your setup — CT scan, Serum electrolytes.

Refer / escalate

Escalate or transfer for coma, GCS 8 or less, absent gag or a falling GCS; any lateralising sign, unequal pupil, scalp injury or need for CT; delirium tremens, benzodiazepine-resistant withdrawal or an escalating benzodiazepine requirement; status epilepticus or seizures outside the 6–48 hour window; fever, neck stiffness, hypotension or haematemesis; high-anion-gap acidosis or suspected methanol or ethylene glycol; and any patient needing airway support, invasive monitoring, phenobarbital, propofol or dexmedetomidine.

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