History
Alcohol withdrawal syndrome is the clinical syndrome that occurs when people who are physically dependent on alcohol suddenly stop drinking or reduce their alcohol consumption.
Alcohol withdrawal syndrome is divided into four categories:
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Minor withdrawal
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Major withdrawal
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Withdrawal seizures
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Delirium tremens (DTs)
Minor withdrawal
Minor withdrawal (withdrawal tremulousness) occurs within 6-24 hours following the patient’s last drink and is characterized by tremor, anxiety, nausea, vomiting, and insomnia.
Major withdrawal (alcoholic hallucinosis)
Major withdrawal (hallucinations) occurs 10-72 hours after the last drink. The signs and symptoms include visual hallucinations and auditory hallucinations, whole body tremor, vomiting, diaphoresis, and hypertension.
Withdrawal seizures
Withdrawal seizures occur within 6-48 hours of alcohol cessation; they are major motor seizures that take place during withdrawal in patients who normally have no seizures and have normal electroencephalograms (EEGs). These seizures are typically generalized and brief. In the absence of treatment, multiple seizures occur in 60% of patients, but the duration between the first and last seizure is usually less than 6 hours. Only 3% of patients go on to develop status epilepticus.
An alcohol withdrawal seizure is frequently the first sign of alcohol withdrawal, and no other signs of withdrawal may be present after the seizure abates. About 30-40% of patients with alcohol withdrawal seizures progress to DTs.
Alcohol withdrawal seizures usually occur only once or recur only once or twice, and they generally resolve spontaneously. If a patient has seizures that are not typical of alcohol withdrawal seizures (such as partial or focal seizures, prolonged seizures, or seizures with a prolonged postictal state) or has signs of significant head trauma, then the underlying cause of the seizure should be investigated. Alcohol-dependent patients have increased rates of idiopathic epilepsy, traumatic brain injury, stroke, and intracranial mass lesions. Moreover, seizures in alcohol-dependent patients may be caused by concomitant use of stimulant drugs, such as cocaine or amphetamines, or by withdrawal from sedative agents, such as benzodiazepines or barbiturates.
Delirium tremens
DTs is the most severe manifestation of alcohol withdrawal. It occurs 3-10 days following the last drink. Clinical manifestations include agitation, global confusion, disorientation, hallucinations, fever, high blood pressure, diaphoresis, and autonomic hyperactivity (tachycardia and hypertension). Profound global confusion is the hallmark of delirium tremens.
CIWA-Ar scale
The most objective and best-validated tool to assess the severity of alcohol withdrawal is the Clinical Institute Withdrawal Assessment for Alcohol, Revised (CIWA-Ar), [5] shown below. This survey consists of 10 items and can be administered rapidly at the bedside in about 5 minutes. The 10 items include nausea and vomiting, anxiety, tremor, sweating, auditory disturbances, visual disturbances, tactile disturbances, headache, agitation, and clouding of sensorium. Zero to 7 points are assigned to each item, except for the last item, which is assigned 0-4 points, with a total possible score of 67.
Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar). The CIWA-Ar is not copyrighted and may be reproduced freely. This assessment for monitoring withdrawal symptoms requires approximately 5 minutes to administer. The maximum score is 67 (see instrument). Patients scoring less than 10 do not usually need additional medication for withdrawal. From Sullivan JT, Sykora K, Schneiderman J, et al. Assessment of alcohol withdrawal: The revised Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA-Ar). British Journal of Addiction 1989;84:1353-1357.
This scale has been demonstrated to have high reliability, reproducibility, and validity, based on comparisons with ratings by experienced clinicians, and has been shown to be usable in detoxication units, psychiatry units, and hospital medical/surgical wards.
The CIWA-Ar scale is intended only for patients who have been drinking recently. It relies on patients’ ability to respond to questions about their symptoms. Patients must be able to communicate and have a clear enough sensorium to reply logically, because many of the items require coherent answers. The CIWA-Ar scale has not been validated in complex medical patients, postsurgical patients, and critically ill patients. Therefore, the CIWA-Ar may not be applicable or reliable in critically ill patients, particularly in mechanically ventilated patients, as it relies on patient communication for information regarding nausea, vomiting, anxiety, tactile and auditory disturbances, and headache.
The CIWA-Ar has been revised for use in medical ICU patients, [6] but it has not been well studied or validated in this population.
A score of greater than 15 is seen in patients with moderate to severe alcohol withdrawal. Patients with a score of greater than 15 or those who have a history of alcohol withdrawal seizures should be treated with medication upon presentation. These patients need to be monitored carefully for the development of DTs. Patients with a score of 8-15, who have mild alcohol withdrawal, should probably also receive drug treatment. Careful and frequent monitoring with the CIWA-Ar is particularly helpful in patients receiving treatment with symptom-triggered drug therapy (also known as prn therapy) and can help avoid over- and under-medication complications that may occur with scheduled benzodiazepine protocols.
A revised version of the CIWA-Ar, called the CIWA-AD, thought to be more user-friendly, is a shorter version (8 items plus pulse measurement), with pulse as a scored item. The 3 CIWA-Ar items assessing the patient’s subjective report of perceptual disturbances are compressed down to a single item. The CIWA-AD is copyrighted, whereas the CIWA-Ar is not. [7]
The RASS (Richmond Agitation Sedation Scale) and Riker SAS (Sedation Agitation Scale) are agitation/sedation scales used in the ICU and appear to have similar efficacy in delirium assessment. [8] They have been recommended for use to monitor drug therapy in ICU patients with severe alcohol withdrawal syndrome but have not been validated in ICU patients for this indication.
Physical Examination
No specific findings on physical examination are diagnostic for delirium tremens (DTs). However, DTs often presents with a coexisting illness, so a careful physical examination should be performed in order to uncover any potentially serious illness that may be present. The patient should be assessed for stigmata of chronic liver disease. Evaluation for signs of trauma should also be included.
Clinical findings associated with DTs may include the following:
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Tachycardia
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Hyperthermia
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Hypertension
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Tachypnea
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Diaphoresis
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Tremor
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Mydriasis
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Altered mental status
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Severe psychomotor agitation
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Fever
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Positional nystagmus
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Global confusion
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Disorientation
Complications
Complications of delirium tremens (DTs) include the following:
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Cardiac arrhythmias
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Oversedation
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Respiratory depression, respiratory arrest, intubation
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Aspiration pneumonitis
Despite appropriate treatment, the current mortality for patients with DTs ranges from 5-15%, but should be closer to 5% with modern ICU management. Mortality was as high as 35% prior to the era of intensive care and advanced pharmacotherapy. The most common conditions leading to death in patients with DTs are respiratory failure and cardiac arrhythmias.
Patients at greatest risk for death are those with extreme fever, fluid and electrolyte imbalance, or an intercurrent illness, such as occult trauma, pneumonia, hepatitis, pancreatitis, alcoholic ketoacidosis, or Wernicke-Korsakoff syndrome.
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Average annual deaths from alcohol.
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Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar). The CIWA-Ar is not copyrighted and may be reproduced freely. This assessment for monitoring withdrawal symptoms requires approximately 5 minutes to administer. The maximum score is 67 (see instrument). Patients scoring less than 10 do not usually need additional medication for withdrawal. From Sullivan JT, Sykora K, Schneiderman J, et al. Assessment of alcohol withdrawal: The revised Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA-Ar). British Journal of Addiction 1989;84:1353-1357.
