Alcohol use disorder and withdrawal

TRY THE SCENARIO!

http://tinyurl.com/

zuh2kgkNigel Fong & Valerie Yeap

Supervisor: Dr Kavitha

Scenario – Q1

An unknown middle-aged Indian gentleman (Mr X) is brought in to A&E by the police.

The police were called to attend to a brawl at a Geylangcoffeeshop. On arrival, Mr X was found seated on the kerboutside the coffeeshop, gesturing wildly and hurling vulgarities at passers-by, with several broken beer bottles beside him. He resisted arrest and required three police officers to restrain him. No identity card was found on him.

At the A&E, Mr X’s vitals are T 37.9, BP 118/76, HR 103, SpO2 95% RA. He is agitated, shouts incoherently, and struggles violently against his handcuffs. As you approach to examine him, he attempts to spit on you.

Scenario - Q1

Which of the following clinical features is NOT consistent with acute alcohol intoxication? (Choose 2 of 7)• Ataxic gait• Coma• Hypoglycaemia• Incontinence• Marked tremor• Seizures• Slurred speech

Scenario - Q1

Which of the following clinical features is NOT consistent with acute alcohol intoxication? (Choose 2 of 7)• Ataxic gait• Coma• Hypoglycaemia• Incontinence• Marked tremor• Seizures• Slurred speech

Scenario – Q2O/E- Disorientated, GCS E4V4M6, unable to give any history. - Unkempt, right periorbital hematoma,right forehead

laceration. - Jaundiced, clubbed. - H S1S2 ESM- L clear- A SNT, 3FB spleen, shifting dullness +- Right calf erythematous and warm, not tense. - Bilateral pitting edema and tinea pedis. - Neuro: PEARL, moving all 4 limbs, normal tone and

reflexes, no overt facial droop (cannot cooperate with further testing).

Scenario - Q2

The investigation of LEAST immediate value is (Choose 1 of 5)• Arterial blood gas• Capillary blood glucose• CT Brain• Digital rectal examination• Toxicology screen

Scenario - Q2

The investigation of LEAST immediate value is (Choose 1 of 5)• Arterial blood gas• Capillary blood glucose• CT Brain• Digital rectal examination• Toxicology screen

Discussion:• Initial impression?• What are the other ddx and what investigations would you

do?

Scenario – Q2O/E- Disorientated, GCS E4V4M6, unable to give any history. - Unkempt, right periorbital hematoma,right forehead

laceration. - Jaundiced, clubbed. - H S1S2 ESM- L clear- A SNT, 3FB spleen, shifting dullness +- Right calf erythematous and warm, not tense. - Bilateral pitting edema and tinea pedis. - Neuro: PEARL, moving all 4 limbs, normal tone and

reflexes, no overt facial droop (cannot cooperate with further testing).

A. Recent ingestion of alcohol

B. Clinically significant maladaptive behavioural orpsychological changes*

• Sexual disinhibition • Aggression • Mood lability • Impaired judgement • Paranoid delusions • Hallucinations

C. ≥1 of the following signs*

• Slurred speech• Incoordination• Unsteady gait• Nystagmus• Impairment in attention / memory• Stupor / coma• Not attributable to a general

medical condition or any other mental disorder

*developing during or shortly after alcohol ingestion

Alcohol Intoxication: DSM V Criteria

Alcohol Intoxication

Cardiovascular effects • ↑ HR • Peripheral vasodilatation • Volume depletion

- Hypothermia and hypovolaemia• “Holiday heart” syndrome

- Tachyarrhythmias, new AF

Respiratory effects• Respiratory depression• Decreased airway sensitivity to

FBs• Decreased ciliary clearance • Aspiration

Metabolic effects• ↓ Glucose • ↓ K• ↓ Mg • ↓ Albumin• ↓ Calcium• ↓ Phosphate• Lactic acidosis

GI effects• Nausea• Vomiting • Diarrhoea• Abdo pain (gastritis, PU,

pancreatitis, acute alcoholic hepatitis)

Uptodate:ethanol intoxicationinadults

Alcohol Intoxication: DDx

Other substance-relatedintoxication

• Cocaine/Opiates• Benzodiazepines• Barbiturates• Tricyclicantidepressants

Neurological • Alcohol withdrawal• Wernike–Korsakoff syndrome• Cerebrovascularaccidents

Trauma • Intracranialbleeding• Subduralhematoma• Concussionsyndromes

Metabolic • Hepaticencephalopathy• Hypoglycaemia• Hyperglycaemia (DKAandHHS)• Electrolyteabnormalities:Na,Ca,

Infection • Sepsis

DDx and Further Ix • Hepatic encephalopathy (think of precipitant) --

Digital rectal examination, LFT• Other drugs --- ABG, toxicology screen• Hypoglycaemia -- Capillary blood glucose• Intracranial pathology --- CT Brain, LP, EEG• Cardiac pathology --- Electrocardiogram, trop• Sepsis -- X-ray of right ankle, Blood cultures

Assessing the alcoholic History• Quantity and type of alcohol consumed • Time course of symptoms • Circumstances • Injuries

Physical examination • Vital signs• Nutritional status • Signs of intoxication and chronic alcohol abuse • Neurological exam and cognitive status • HLAC

Alcohol units and safe limits

National dietary guidelines: Not more than 2 standard drinks / day• At least 2 alcohol-free days • Standard drink = 10mg alcohol

Scenario - Q3

Initial blood investigations reveal:- Hb 8.2 MCV 104 TW 15 Plt 103- Na 140 K 4.0 Cl 95 HCO3 23 Cr 78- Corrected Ca 2.23 PO4 1.2 Mg 0.9- Alb 20 Bil 53 ALP 189 ALT 235 AST 378- CRP 78 Procal 0.8

CT brain and Chest X ray is normal.

Scenario - Q3

The following interventions are helpful EXCEPT (Choose 3 of 10)• Activated charcoal• Oesophagoduodenoscopy• Gastric lavage• IV Augmentin• IV Naloxone• IV Omeprazole• IV Thiamine• PO Lactulose• PO Folic acid• PO Spironolactone

Scenario - Q3

The following interventions are helpful EXCEPT (Choose 3 of 10)• Activated charcoal• Oesophagoduodenoscopy• Gastric lavage• IV Augmentin• IV Naloxone• IV Omeprazole• IV Thiamine• PO Lactulose• PO Folic acid• PO Spironolactone

Alcohol Intoxication

Problem list in this patient1. Alcohol intoxication (?coingestant)2. Cellulitis3. Alcoholic cirrhosis

Discussion:• Initial management of this patient?

Initial Management

For alcohol intoxication:• Resuscitation, especially if there are other injuries• Correction of electrolyte abnormalities • No role for gastric lavage / activated charcoal• No role for naloxone (’coma cocktail’) unless strong clinical

suspicion for coingested opoid• Wernicke encephalopathy prophylaxis: thiamine

For cellulitis:

For alcoholic cirrhosis:

Initial Management

For alcohol intoxication:

For cellulitis:• Exclude necrotising fasciitis / abscess especially if pt cannot

give adequate history• Exclude concomitant arterial or venous insufficiency• Look for ‘point of entry’ eg. Tinea pedis.• Antibiotics• Raise limb

For alcoholic cirrhosis:

Initial Management

For alcohol intoxication:

For cellulitis:

For alcoholic cirrhosis:• Ensure daily BO with lactulose • Management of hypoalbuminaemia with edema/ascites:

spironolactone / furosemide • Notice Hb is low; consider workup, KIV scopes for BGIT• Management of the cause (see later)

Scenario – Q4The forehead laceration is sutured and he is started on IV augmentin. He is sent to GWThe police officer manages to him as Mr Adi, a 53/Indian/M with a known PMHx of Child’s C alcoholic cirrhosis with previous variceal bleed, COPD, and DM. He had defaulted all follow up appointments and medications for the past 2 years.

His old meds are restarted, including: Aspirin 100mg OM Propranolol 10mg OMSeretide inhaler 2 puff BD Metformin 500mg BDLactulose 10ml TDS Senna 2 tab ONFurosemide 20mg OM Spironolactone 50mg OM

Scenario – Q4

Two days later, you are called to see Mr Adi for vomiting and agitation. His vital signs are: BP 112/72, HR 92, T 37.5, SpO2 96% RA. You find him trashing about, attempting to climb out of bed. His hands are shaking and he is diaphoretic. He says that he is in the bus, and he is trying to get out because he can feel cockroaches crawling all over him and hears threatening voices. The physical examination is otherwise normal.

Scenario – Q4

Your initial management is (Choose 1 of 5)• IV diazepam 5mg• IM haloperidol 1mg• Physical restraints• Repeat CT brain• Repeat septic workup

Scenario – Q4

Your initial management is (Choose 1 of 5)• IV diazepam 5mg• IM haloperidol 1mg• Physical restraints• Repeat CT brain• Repeat septic workup

Pathophysiology

• Acutely - Alcohol increases CNS GABA (inhibitory neurotransmitter)

• With chronic alcohol use, CNS down-regulates GABA receptor response

• On stopping alcohol, sudden decrease in GABA àCNS excitation

Pathophysiology

Shivanand 2013IndustrialPsychiatry

Intoxication Withdrawal Delirium tremensOnset <8h afterdrink 8h onwards 48-72h onwardsDuration <2days 2-3 days

(upto5)2-3 days(upto7)

Physicalfeatures

IncoordinationSlurredspeechNystagmusAtaxicgaitInattention

Autonomic:- tremor- diaphoresis- tachycardia

Nausea/vomitingHeadache

More severeform+Markedtremor+Delirium+Seizure

Psychfeatures

DisinhibitionAgitation

HallucinationInsomniaAgitation

More severeform

Spectrum & Time course

Delirium tremens: DSM V CriteriaA. Criteria for alcohol withdrawal

Cessation of or reduction in heavy and prolonged use of alcohol

≥2 of the following symptoms• Autonomic hyperactivity • Hand tremor • Insomnia • Nausea or vomiting • Transient hallucinations or illusions • Psychomotor agitation• Anxiety • Generalised tonic-clonic seizures

B. Criteria for delirium

• Decreased awareness and attention

• Disturbance in awareness,memory, orientation, language, visuo-spatial ability, perception that is a change from the normal level and fluctuates in severity during the day

• No evidence of coma or other neurocognitive disorders

*Patient must meet both the criteria for both alcohol withdrawal and delirium is considered to have delirium tremens

Grading of severity: CIWA

• Nausea/vomiting 7 = constant nausea/vomiting• Tremor 7 = even with arms extended• Sweats 7 = drenching• Anxiety 7 = acute panic• Tactile disturbance 7 = continuous hallucinations• Auditory disturbance 7 = continuous hallucinations• Visual disturbances 7 = continuous hallucinations• Headache 7 = extremely severe• Agitation 7 = trashing about / pacing• Orientation 4 = disorientated (max 4)

< 8 Mild | 8-15 Moderate | > 15 Severe

Assessment Protocol a. Vitals, Assessment Now. b. If initial score t 8 repeat q1h x 8 hrs, then if stable q2h x 8 hrs, then if stable q4h. c. If initial score < 8, assess q4h x 72 hrs. If score < 8 for 72 hrs, d/c assessment. If score t 8 at any time, go to (b) above. d. If indicated, (see indications below) administer prn medications as ordered and record on MAR and below.

Date

Time

Pulse RR

O2 sat BP

Assess and rate each of the following (CIWA-Ar Scale): Refer to reverse for detailed instructions in use of the CIWA-Ar scale. Nausea/vomiting (0 - 7) 0 - none; 1 - mild nausea ,no vomiting; 4 - intermittent nausea; 7 - constant nausea , frequent dry heaves & vomiting.

Tremors (0 - 7) 0 - no tremor; 1 - not visible but can be felt; 4 - moderate w/ arms extended; 7 - severe, even w/ arms not extended.

Anxiety (0 - 7) 0 - none, at ease; 1 - mildly anxious; 4 - moderately anxious or guarded; 7 - equivalent to acute panic state

Agitation (0 - 7) 0 - normal activity; 1 - somewhat normal activity; 4 - moderately fidgety/restless; 7 - paces or constantly thrashes about

Paroxysmal Sweats (0 - 7) 0 - no sweats; 1 - barely perceptible sweating, palms moist; 4 - beads of sweat obvious on forehead; 7 - drenching sweat

Orientation (0 - 4) 0 - oriented; 1 - uncertain about date; 2 - disoriented to date by no more than 2 days; 3 - disoriented to date by > 2 days; 4 - disoriented to place and / or person

Tactile Disturbances (0 - 7) 0 - none; 1 - very mild itch, P&N, ,numbness; 2-mild itch, P&N, burning, numbness; 3 - moderate itch, P&N, burning ,numbness; 4 - moderate hallucinations; 5 - severe hallucinations; 6 – extremely severe hallucinations; 7 - continuous hallucinations

Auditory Disturbances (0 - 7) 0 - not present; 1 - very mild harshness/ ability to startle; 2 - mild harshness, ability to startle; 3 - moderate harshness, ability to startle; 4 - moderate hallucinations; 5 severe hallucinations; 6 - extremely severe hallucinations; 7 - continuous.hallucinations

Visual Disturbances (0 - 7) 0 - not present; 1 - very mild sensitivity; 2 - mild sensitivity; 3 - moderate sensitivity; 4 - moderate hallucinations; 5 - severe hallucinations; 6 - extremely severe hallucinations; 7 - continuous hallucinations

Headache (0 - 7) 0 - not present; 1 - very mild; 2 - mild; 3 - moderate; 4 - moderately severe; 5 - severe; 6 - very severe; 7 - extremely severe

Total CIWA-Ar score:

PRN Med: (circle one) Diazepam Lorazepam

Dose given (mg): Route:

Time of PRN medication administration:

Assessment of response (CIWA-Ar score 30-60 minutes after medication administered)

RN Initials

Scale for Scoring: Total Score = 0 – 9: absent or minimal withdrawal 10 – 19: mild to moderate withdrawal more than 20: severe withdrawal

Indications for PRN medication: a. Total CIWA-AR score 8 or higher if ordered PRN only (Symptom-triggered method). b. Total CIWA-Ar score 15 or higher if on Scheduled medication. (Scheduled + prn method) Consider transfer to ICU for any of the following: Total score above 35, q1h assess. x more than 8hrs required, more than 4 mg/hr lorazepam x 3hr or 20 mg/hr diazepam x 3hr required, or resp. distress.

Patient Identification (Addressograph) Signature/ Title Initials Signature / Title Initials

Alcohol Withdrawal Assessment Flowsheet (revised Nov 2003)

Outcome

• Delirium tremens has a mortality of 1-4%, especially if the diagnosis is missed

• Causes of death: hyperthermia, arrhythmia, seizure, other medical disorders

• Risk factors• Older age• Comorbids and other medical issues• Previous DT / seizure• CIWA > 15• Seizure• Co-ingested drugs of abuse.

Schuckit MA.Recognitionandmanagementofwithdrawaldelirium(deliriumtremens).NEnglJMed. 2014Nov27;371(22):2109-13.

Management

• Benzodiazapines is the mainstay to inhibit GABA receptors and counter sudden decrease in GABA

• Examples• PO/IV Lorazepam 1-2 mg• PO/IV Diazepam 5-10mg • Chlordiazepoxide: 50-100mg (max 300mg / 24h)

• Duration of action: chlordiazepoxide = diazepam > lorazepam > midazolam

• Caution in advanced liver disease (accumulates: use benzo with shorter half life).

Management

• How frequently to give?• Symptom triggered dosing results in less drug use and

shorter treatment duration• Practically:

• Use CIWA score; monitor q6-8h if mild, more if severe.• Benzos PRN aiming CIWA < 8• Consider regular benzos if CIWA >15

e.g. Diazepam 10mg TDS x 2/7, 5mg TDS x 2/7, and wean

• Bear in mind DT peaks after 72h

Severe alcohol withdrawal

Scenario – Q5

Mr Adi is put on CIWA scoring. Over the next day his mental state improves clinically and benzodiazapines are switched to symptom-triggered dosing; they are completely stopped by day 4 of admission. His cellulitis also improves and antibiotics are oralized.

On day 5 of admission, you are called to see Mr Adi. He still complains of hearing voices – this time he hears his ex-wife (who divorced him because of his alcohol habits) taunting him. He knows that the voice is not real. He is otherwise alert, orientated, and conversant. He has no tremor, nausea or vomiting, headache, or sweating.

Scenario – Q5

Your initial management is (Choose 1 of 5)• IV diazepam 5mg• PO risperidone 1mg• Physical restraints• Repeat CT brain• Repeat septic workup

Scenario – Q5

Your initial management is (Choose 1 of 5)• IV diazepam 5mg• PO risperidone 1mg• Physical restraints• Repeat CT brain• Repeat septic workup

Alcoholic hallucinosis

• Occurs in 5-10% upon abstaining from heavy alcohol consumption

• Patient otherwise orientated, no other features of DT • It involves unpleasant sound or threatening voices but

absence of thought disorder or mood incoherence. • Can persist 6 months after abstinence • Good prognosis and shows rapid response to antipsychotic.

MelvynZhangetal.Masteringpsychiatry(2016).https://mzhtb-tor.com/

Scenario – Q6

Mr Adi’s voices stop. On day 7 of admission, you are again CTSP. He is agitated and attempting to climb out of bed.

Regarding his recurrence of AMS, which statement is TRUE? (Choose 1 of 5)• His benzodiazapines were prematurely stopped• Alcohol withdrawal is likely to explain this AMS• Refeeding syndrome is likely to explain this episode of

altered mental status• Normal CT scan in A&E essentially rules out SDH• Ongoing thiamine supplementation makes Wernicke

encephalopathy unlikely

Scenario – Q6

Mr Adi’s voices stop. On day 7 of admission, you are again CTSP. He is agitated and attempting to climb out of bed.

Regarding his recurrence of AMS, which statement is TRUE? (Choose 1 of 5)• His benzodiazapines were prematurely stopped• Alcohol withdrawal is likely to explain this AMS• Refeeding syndrome is likely to explain this episode of

altered mental status• Normal CT scan in A&E essentially rules out SDH• Ongoing thiamine supplementation makes Wernicke

encephalopathy unlikely

Scenario – Q7

Mr Adi’s voices stop. On day 7 of admission, you are again CTSP. He is agitated and attempting to climb out of bed. Mr Adi’s vital signs are: BP 134/78, HR 102, T 37.3, SpO2 89% RA. He is found in respiratory distress, with bilateral wheeze and pursed-lip breathing. ABG: pO2 46, pCO2 34, pH 7.46, Bicarb 26Supplemental oxygen, nebulization, and IV steroids are administered. A chest X ray is hyperinflated but otherwise does not show any evidence of consolidation or effusion.

Scenario – Q7

In addition to the above management, you will also -• Escalate antibiotics• Give IV diazepam• Order an emergent CT brain• Suspend propranolol• Resume CIWA charting and regular benzodiazapines

Scenario – Q7

In addition to the above management, you will also -• Escalate antibiotics• Give IV diazepam• Order an emergent CT brain• Suspend propranolol• Resume CIWA charting and regular benzodiazapines

Late complications of alcohol• Neurological / psychiatric

• Wernicke encephalopathy / Korsakoff dementia

• Alcohol hallucinosis• Reduced seizure threshold• Bilateral cerebellar

dysfunction• Proximal neuropathy• Peripheral neuropathy

• Gastrointestinal• Alcoholic hepatitis /

cirrhosis• HCC• Gastritis• Pancreatitis

• Other systems:• Cardiomyopathy, AF• Macrocytic anaemia• Fetal toxicity

MelvynZhangetal.Masteringpsychiatry(2016).https://mzhtb-tor.com/

Wernicke Encephalopathy

• Clinical diagnosis: 2 of 4 signs • Dietary deficiencies• Eye signs (opthalmoplegia)• Cerebellar dysfunction (ataxia)• AMS or mild memory impairment

• MRI if needed (reversible cytotoxic edema)• Treatment: IV thiamine 200-500mg TDS, before any glucose

(carbohydrate precipitates WE). • Thiamine is indicated in any suspected WE, it is safe

GalvinR1,Bråthen G,Ivashynka A,Hillbom M,Tanasescu R,LeoneMA.EFNSguidelines fordiagnosis, therapyandpreventionofWernickeencephalopathy.Eur JNeurol.2010Dec;17(12):1408-18

Scenario – Q8

Mr Adi recovers and is discharged home. You take the opportunity to counsel him on alcohol cessation. He asks to be given “one more week to enjoy himself” after which he promises to go “cold turkey”.

Scenario – Q8

All the following statements are correct EXCEPT -• Mr Adi should be discharged with disulfiram. • Mr Adi should be discouraged from going “cold turkey” in a

week’s time (as he suggests)• Mr Adi should be referred for psychotherapy and addiction

counselling • Mr Adi should receive hepatitis A and B vaccination.• Mr Adi’s readiness to change should be explored at every

subsequent TCU.

Scenario – Q8

All the following statements are correct EXCEPT -• Mr Adi should be discharged with disulfiram. • Mr Adi should be discouraged from going “cold turkey” in a

week’s time (as he suggests)• Mr Adi should be referred for psychotherapy and addiction

counselling • Mr Adi should receive hepatitis A and B vaccination.• Mr Adi’s readiness to change should be explored at every

subsequent TCU.

Managing the chronic alcoholic

• Manage comorbids• Brief intervention each visit

• Ask about use• Advice to quit or reduce• Assess willingness• Assist to quit or reduce• Arrange follow-up.

Managing the chronic alcoholic

• Manage comorbids• Brief intervention each visit• Non-pharmacological: CBT, help groups• Pharmacological:

• Naltrexone: opioid antagonist (make alcohol less rewarding).

• Acamprosate: glutamate antagonist (reduce craving)• Disulfiram: aversive therapy (taking alcohol results in

unpleasant side effects).

Uptodate:Pharmacotherapyforalcoholusedisorder

Pitfalls in managing the alcoholic

• Failure to consider differentials; overly hasty diagnosis of alcohol withdrawal

• Failure to consider withdrawal phenomena in an alcoholic admitted for non-alcohol medical conditions

• Failure to recognize DT and treat with benzodiazapines.

Further reading

• Schuckit MA. Recognition and management of withdrawal delirium (delirium tremens). N Engl J Med. 2014 Nov 27;371(22):2109-13.

• Michael F. Mayo-Smith et al. Management of Alcohol Withdrawal Delirium. Arch Intern Med. 2004;164:1405-1412