Alcohol withdrawal need not be a dramatic illness. Identification of susceptible patients and early gentle treatment are the keys to success. Treatment delayed until the patient is confused or hallucinating is much less likely to be effective.

A large part of the alcohol withdrawal syndrome is subjective. For this reason nursing techniques incorporating firm reassurance and a calm atmosphere have been shown to be effective and should always be tried first. The patients who are risk should be identified and observed for early signs.

The severity and pattern of alcohol withdrawal are affected markedly by:

• the setting in which it occurs
• the state of mind and expectations of the patient
• attitudes and behaviours of others

As the syndrome is perpetuated by stress it is important to pay attention to the following factors:

• Provide a comfortable and quiet environment with reduced external stimuli
• Shadows may confuse the patient and bright lighting may create photophobia
• Be confident and supportive with a calm approach
• Give lots of reassurance and reality orientation
• Don't use jargon and remain at the bedside for as long as necessary

Patients are at risk for alcohol withdrawal if they have any of the following:

• An alcohol intake of 100 g/day (10 standard drinks) or more on a regular basis
• A blood alcohol concentration of 0.2 g% on admission with little obvious impairment of consciousness
• A recent (within 3 months) documented episode of alcohol withdrawal
• Admission with an alcohol related illness and currently drinking

N.B. An intercurrent condition that is causing tissue hypoxia (pneumonia, shock), pain or other stress, or a recent or imminent general anaesthetic will put a patient at increased risk.

This is the most common form of delirium seen as a complication of alcohol withdrawal and is much commoner than Delirium Tremens (see below) which is feared but rare. Once the patient has developed disorientation, disordered attention and an abnormal state of consciousness, the condition will follow its natural course and management is supportive only.

N.B. Sedation should be prescribed and given only to control agitation. Prescription will be at the discretion of the Medical Officer, appropriate for the management of that patient and not strictly according to the assessment score.

This can occur either as a solitary symptom or accompanied by autonomic hyperactivity. Most cases will respond to haloperidol given orally or IMI The dose may need to be repeated in two to three hours. There is no need to give additional treatment (over the alcohol withdrawal treatment) for the hallucinations if the patient is calm and insight is preserved.

In general terms treatment of the withdrawal seizures is the treatment of the withdrawal. Exclude other causes of convulsions, e.g. idiopathic or post traumatic epilepsy. Load with diazepam if this has not already been done. 50% of patients will only suffer a single fit.

Alcohol Withdrawal Seizures ETOH.pdf

This not to be confused with simple hallucinations or a withdrawal confusional state. Delirium tremens is extremely rare, it has three essential elements, namely

• Acute hallucinations
• Autonomic hyperactivity
• Circulatory collapse

Each case should be treated on its merits, but the principles are:

• Give fluid replacement
• Major tranquilliser are often required
• Correct electrolyte abnormalities (including magnesium)
• Check for hypoxia (arterial blood gases)
• Close monitoring of all patients
• Identify any underlying cause(s)

In almost all cases a major intercurrent condition is present.

The withdrawal assessment scale is commenced on admission or as soon as possible after a history is obtained which indicates that the patient is at risk. It is to be maintained for THREE days then ceased if no signs of withdrawal are “present”, otherwise continued until no withdrawal signs have been present for 24 hours.

The withdrawal assessment is divided into nineteen clinical categories which require the nurse (or doctor) to assess and designate a corresponding score. These scores are entered into the column adjacent to each clinical category and a total score given at the bottom of the score sheet.

For example: A patient with a temperature of 37.2 C would have a score of 1 for temperature.

Temperature (per axilla)
1. 37-37.5,
2. 37.5-38,
3. Greater than 38

Assessment is carried out initially at 4th hourly intervals, if the total score is greater than or equal to 10 increase to 2nd hourly. If the total score is equal to or greater than 15 increase to hourly.

Alcohol Withdrawal procedure 07 v 21.doc [326 KB]

In patients with two consecutive scores of 15 or a single score of 20 treat with diazepam.

The following regime is recommended:

Administration of diazepam orally until the score is below 10. To be reviewed after 3 doses, no more than a total of 6 doses to be given.
All patients should be assessed by a Medical Officer, or at least a Medical Officer notified, prior to sedation being given. This is particularly important if a PRN order of sedation was written in advance, or if the Medical Officer who prescribed the order in advance is no longer on duty, or if it is the first dose of sedation. The appropriate nurse should document in the history, examination and progress notes that this notification process has occurred.

The score and protocol are NOT a substitute for the proper investigation of confusional states and seriously ill or confused patients should not be sedated by junior medical staff without seeking advice from a registrar or more senior medical officer.

BAP_Guidelines.pdf [280 KB]
Alcohol Faxsheet 2.doc [55 KB]

In Australia, the NSW Drug and Alcohol Specialist Advisory service provides management information for health professionals only. Phone (02) 9516 8156 or (008) 023 687.

Foy, A. The Management of Alcohol Withdrawal. The Medical Journal of Australia 1986; 145, (July 7): 24-27.