Medical Management of Alcohol Withdrawal



Canberra Hospital and Health ServicesClinical Guideline Medical Management of Alcohol Withdrawal Contents TOC \h \z \t "Heading 1,1,Heading 2,2" Contents PAGEREF _Toc497814646 \h 1Guideline Statement PAGEREF _Toc497814647 \h 2Scope PAGEREF _Toc497814648 \h 2Section 1 – Alcohol Withdrawal PAGEREF _Toc497814649 \h 2Section 2 – Clinical Indicators for commencing an AWS PAGEREF _Toc497814650 \h 3Section 3 – Guidance in the use of AWS PAGEREF _Toc497814651 \h 3Section 4 – History of alcohol withdrawal seizures PAGEREF _Toc497814652 \h 4Section 5 – Indications for Transfer of people from AMC or DMHU to the Canberra Hospital PAGEREF _Toc497814653 \h 5Implementation PAGEREF _Toc497814654 \h 6Related Policies, Procedures, Guidelines and Legislation PAGEREF _Toc497814655 \h 6References PAGEREF _Toc497814656 \h 6Definition of Terms PAGEREF _Toc497814657 \h 7Search Terms PAGEREF _Toc497814658 \h 7Attachments PAGEREF _Toc497814659 \h 7Attachment 1 – Features of withdrawal PAGEREF _Toc497814660 \h 8Attachment 2 – Alcohol Withdrawal Scale PAGEREF _Toc497814661 \h 9Attachment 3 – Example of Medication Order Chart for PRN Diazepam PAGEREF _Toc497814662 \h 11Attachment 4 – Alcohol withdrawal regimes PAGEREF _Toc497814663 \h 12Guideline StatementThis guideline provides Canberra Hospital and Health Services (CHHS) Medical and Nursing staff guidance relating to the medical management of Alcohol Withdrawal including the following:Clinical indicators for commencing an assessment using the Alcohol Withdrawal Scale (AWS); The use of the AWS score in conjunction with the medication order ; Indications for when advice is to be sought from the Alcohol and Drug Service (ADS) Medical Officers and Consultation Liaison (CL)Circumstances under which people experiencing alcohol withdrawal must be transferred from Alexander Maconochie Centre (AMC) or Dhulwa Mental Health Unit (DMHU).Back to Table of ContentsScopeThis clinical guideline is for use by all ACT Health medical and nursing staff including Consultation and Liaison (CL) nurses and Medical Officers from the Alcohol and Drug Service (ADS).Back to Table of ContentsSection 1 – Alcohol WithdrawalAlcohol dependence or heavy alcohol consumption can often be unrecognised, particularly when a person is admitted to hospital for surgery or other reasons. Alcohol withdrawal can lead to seizures, hallucinations and severe withdrawal syndromes (previously called Delirium Tremens – the “DT’s”), that can be life threatening. It is important that clinicians are able to assess, recognise and respond to the symptoms of withdrawal so it can be treated early.Alcohol withdrawal can start 6 to 12 hours after the last drink and can be independent from a Breath Alcohol Level (BAL) returning a positive reading. The severity of alcohol withdrawal ranges from mild to moderate to severe. The early recognition and correct medical management of the initial, milder stages of withdrawal is crucial in preventing progression into the severe, life threatening stages. Seizures can occur at any time during withdrawal, but usually occur within the first 48 hours.Back to Table of Contents Section 2 – Clinical Indicators for commencing an AWSThe following are clinical indicators for commencing an AWS that clinicians should be aware of:A history of heavy drinking or alcohol dependence, and less than 10 days since the last consumption of alcohol by a patient.A regular daily intake of 80 grams of alcohol for several months or weeks prior to admission.A regular consumption of smaller amounts of alcohol in conjunction with significant doses of other Central Nervous System (CNS) depressants, e.g. benzodiazepines.A history of previous episodes of alcohol withdrawal.A history of previous alcohol withdrawal seizures or other serious withdrawal symptoms.A current admission for an alcohol related reason.A previous history of an alcohol related condition e.g. alcoholic hepatitis, alcoholic cardiomyopathy, pancreatitis, oesophageal varices, and liver disease.A characteristic physical appearance indicating harmful alcohol use, e.g. facial vascularisation, signs of liver disease, e.g. ascites, jaundice, muscle wasting, spider naevi, palmar erythema etc.Recent pathology results showing raised serum Gamma Glutamyl Transpeptidase (GGT) and/or raised mean cell volume (MCV). Note that these are non-specific and may be raised for a number of unrelated reasonsA history of/ or reported symptoms such as hypertension, anxiety, sleep disturbance, agitation, tremor, sweatiness, nausea/vomiting, or early morning retching, possibly due to alcohol withdrawal.Back to Table of Contents Section 3 – Guidance in the use of AWSThe AWS form can be found on the Clinical Forms Register. Staff should always record the time of the last alcoholic drink, and the blood or breath alcohol reading at the time of admission. This will provide a more accurate diagnosis of any risk of withdrawal and its anticipated time of onset, and/or poly drug overdose or concurrent illness or injury.The most systematic and useful way to measure the severity of withdrawal is to use a withdrawal scale. This provides a baseline against which changes in withdrawal severity may be measured over time thus avoiding both under and overdosing with benzodiazepines and other symptomatic medications for alcohol withdrawal syndromes.The Alcohol Withdrawal Scale does not diagnose the alcohol withdrawal syndrome, but merely guides in the identification of symptoms indicative of the severity of an already diagnosed withdrawal syndrome. (Attachment 1)The AWS is a 6 item scale for assessing the clinical course of alcohol withdrawal. The aim is to keep the AWS score less than 5. (Attachment 2)Association between a medication dosage scale and AWS scoreThe most commonly prescribed pharmacological treatment for alcohol withdrawal is Diazepam because it is long acting, there is a cross tolerance with alcohol and it has anti-convulsant properties. A potential risk is over sedation with benzodiazepines, but that is unusual and more often the dose of diazepam prescribed in the Hospital setting is inadequate to control withdrawal symptoms. Benzodiazepines are generally very safe drugs to use in these circumstances.Diazepam 10-20mg (orally) should be prescribed in order to keep AWS score less than 5 (see attachment 3 for example medication order). If more than around 80 mg of Diazepam is required over 24 hours, a medical review is usually indicated. During normal business hours the ADS Medical officer should be consulted; after hours a medical review by the RMO/ Medical Registrar on call should be sought (see Alcohol Withdrawal regimes – Attachment 4).People in the AMC with moderate to severe alcohol withdrawal should be reviewed by the AMC AOD Nurse (Monday to Friday) until alcohol withdrawal has stabilised. The AOD nurse will liaise with the Medical Officer or on-call Medical Officer (after hours) as required. Oversight of weekend treatment and care should be discussed with the Clinical Director, JHS.Back to Table of Contents Section 4 – History of alcohol withdrawal seizuresAlert:Any seizure must be taken seriously and investigated for causesPeople with a past history of alcohol withdrawal seizures should usually receive diazepam in a loading protocol i.e.: 10-20 mg hourly to 60mg in total (titrated to patients’ level of sedation). Staff should observe for over sedation.Diazepam should only be withheld if signs of benzodiazepine intoxication or over-sedation is present.Alcohol withdrawal management where Diazepam sedation is contraindicated:Acute or chronic liver diseaseThe advice of an ADS specialist medical officer is necessaryIt is essential to determine that the person is in withdrawal and not hepatic encephalopathy as injudicious sedation may be dangerousOxazepam may be preferable to Diazepam because it has a shorter half-life and it has no active metabolites (15mg Oxazepam =5mg Diazepam).Chronic airflow limitationThe advice of an ADS specialist medical officer is necessaryDiazepam should not be used if a patient has respiratory failure as it may worsen the condition due to respiratory depressionAn Oxazepam regime e.g. 15-30mg prn, may be the choice in this instance as it has a shorter half-lifeNo oral intake (nil by mouth)Consult specialist medical officer for advice as to IV or IMI sedationIndications for when advice/review should be sought from Alcohol and Drug ServicesAt request of patient (D&A Consultation Liaison see patients in the Hospital on a daily basis)If patient has received total 80mg diazepam in 24 hours for alcohol withdrawal, review by at least the RMO is usually indicated (this is to ensure that it is alcohol withdrawal and not another medical condition being measured)The patient is demonstrating symptoms of severe withdrawal A patient whose withdrawal syndrome is difficult to manageThe patient suffers from liver diseaseIf unsure of medication regime for alcohol withdrawal or loading dose regime for patient with a history of seizures Patients with thiamine deficiencyPatients with moderate to severe alcohol withdrawal should be reviewed by ADS CL daily until alcohol withdrawal has stabilised (Refer to Attachment 1)During normal business hours the ADS Medical officer should be consulted; after hours a medical review by the RMO/ Medical Registrar on call should be sought Back to Table of ContentsSection 5 – Indications for Transfer of people from AMC or DMHU to the Canberra HospitalWhile it is often possible to clinically manage detainees in alcohol withdrawal within the AMC or DMHU, there are numerous circumstances when it is inappropriate to do so, and transfer to the Canberra Hospital is required. These circumstances include:Alcohol withdrawal management where Diazepam sedation is contraindicatedAcute or chronic decompensated liver diseaseRespiratory failureNo oral intake for a prolonged period, with assessed danger of re-feeding complicationsExcessive sedation, possibly from diazepam over-dosingIf patient has received a total of 100mg diazepam in 24 hours The person is demonstrating symptoms of severe withdrawalA person whose withdrawal syndrome is difficult to manageIf unsure of medication regime for alcohol withdrawal or loading dose regime for patient with a history of seizures, orPatients with signs/symptoms of clinical thiamine deficiency (peripheral neuropathy, Wernicke-Korsakoff syndrome).Back to Table of ContentsImplementation This guideline will be communicated to all staff through an all staff DDG CHHS email alert and through line managers.Back to Table of ContentsRelated Policies, Procedures, Guidelines and LegislationProceduresEmergency Department and Mental Health Interface Operational ProcedureMedication Handling PolicyGuidelines National Safety and Quality Healthcare Services Standards 2012 Mental Health Standards 2010Back to Table of ContentsReferencesFlinders University and Drug & Alcohol Services Council (2003). Alcohol, Tobacco & other Drugs. Guidelines for Nurses & Midwives: Clinical Guidelines. Flinders University and Drug & Alcohol Services Council, South Australia.NSW Health Detoxification Clinical Practice Guidelines 2000-2003,health..au/...health/.../detoxification clinical practice guidelines.pdf, viewed Friday 18 November 2011.New South Wales (NSW) Health (2007). NSW Drug and Alcohol Withdrawal Clinical Practice Guidelines. New South Wales Department of Health, North Sydney.Turning Point (2007). Vocational and Technical Education Training Packages Student Notes, Turning Point Alcohol and Drug centre, Fitzroy, Victoria.Back to Table of ContentsDefinition of Terms Alcohol Withdrawal Scale (AWS): a 7 item scale with a potential maximum score of 27, used to assess levels of alcohol withdrawal and ‘symptom-triggered’ prn sedation.Diazepam: a benzodiazepine in the sedative-hypnotic group of drugs which have a general depressant effect that increases with the dose.Alcohol Withdrawal Seizures: occurring early (usually 7–24 hours after the last drink). They are grand mal in type (i.e. generalised, not focal) and usually (though not always) occur as a single episode.BAL: breath alcohol levelPolydrug overdose: Polydrug use is when a person uses more than one type of drug – either at the same time or at different times. Polydrug use can lead to more problems than using just one type of drug. For example, it can increase the chances of overdose.Back to Table of ContentsSearch Terms Alcohol, Withdrawal, Consultation and Liaison, Seizures, AWS, BALBack to Table of ContentsAttachmentsAttachment 1 – Features of withdrawalAttachment 2 – Alcohol Withdrawal ScaleAttachment 3 – Example of Medication Order Chart for PRN DiazepamAttachment 4 – Alcohol withdrawal regimes Disclaimer: This document has been developed by Health Directorate, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.(to be completed by the HCID Policy Team)Date AmendedSection AmendedApproved ByEg: 17 August 2014Section 1ED/CHHSPC ChairAttachment 1 – Features of withdrawalMild withdrawalMild rise in temperature eg 37 degrees CelsiusMild anxietySlight tremorMild sweatingNausea and vomitingHeadachesMild hypertensionTachycardiaModerate withdrawalMild rise in temperatureModerate anxietyModerate sweatingNausea and vomitingTremorRestlessness/agitationDiarrhoeaMild to moderate hypertensionInsomnia Severe withdrawalAcute anxietyAgitationConvulsions/seizuresDehydrationExcessive sweatingMarked tremorTachycardiaHypertensionNausea and vomitingDiarrhoeaDisorientation/confusionFeverHallucinationsHypersensitivity to stimulationNote: The usual course of withdrawal is 5-7 daysAttachment 2 – Alcohol Withdrawal Scale3784603106420Sample00Sample5778503777615Sample00SampleAttachment 3 – Example of Medication Order Chart for PRN Diazepam3492491431925Sample00SampleAttachment 4 – Alcohol withdrawal regimesMild withdrawal predicted – Diazepam 10-20mg prn to keep AWS less than 5 when there is:No other likely medical condition that may complicate or mimic withdrawalNo history of withdrawal seizureDaily intake less than 80 grams (60 grams in women)Daily intake greater than 80 grams (60 grams in women) and the person is under 30 years oldHistory of previous mild withdrawal syndromeSignificant alcohol withdrawal predicted – Diazepam loading is recommended (total 60mg) plus e.g. Diazepam 10-20mg to keep AWS less than 5 when there is:History of withdrawal seizuresPast history of severe withdrawal ................
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