The Newcastle Upon Tyne Hospitals

NHS Trust

Newcastle, North Tyneside and Northumberland

Mental Health NHS Trust

MANAGEMENT OF ACUTE ALCOHOL WITHDRAWAL

SUMMARY PROTOCOL

Goals: To minimise morbidity and mortality and maximise patient comfort through:
• recognition of all alcohol misuser hospital attendees.
• identification of sub-groups with, or at risk of, potentially life-threatening complications.
• prompt initiation of appropriate medical management.

Background: Alcohol misuse is a problem throughout the hospital. For example:

• around 20% of patients admitted for illnesses unrelated to alcohol are drinking at potentially
hazardous levels.
• 12% of A&E attendances have been shown to be directly related to alcohol.
• 34-36% of orthopaedic admissions and 33-50% of head injury patients have been found to be
hazardous or harmful drinkers.

Alcohol misuse is often unrecognised, the ‘skid row’ presentation being an uncommon example.
Other misusers may be less obvious and may:
• be, or appear to be, sober and in every way unexceptional.
• have few, if any, signs of alcohol misuse or only non-specific symptoms.
• have symptoms overlooked during an intercurrent illness.

Morbidity and mortality: Two life-threatening withdrawal-related complications make detection of

the ‘less obvious’ misuser vital.

1. Delirium tremens (DTs) occurs in about 5% of patients during withdrawal, usually 2 to 5

days after alcohol cessation or decreased intake. DTs is fatal in 15-20% of inappropriately
managed patients, whilst appropriate prophylactic sedation reduces mortality to 1-5% (see
management algorithm).

2. Wernicke’s encephalopathy (WE) has been shown to occur in 12.5% of alcohol misusers.
It may develop rapidly or over a number of days. Inappropriately managed it is the primary or
a contributory cause of death in 17% of patients and results in permanent brain damage in
85% of survivors. WE is initially reversible with parenteral B-vitamins so treatment should be
initiated immediately a diagnosis is suspected or risk factors identified (see management
algorithm).
 Guideline for the Management of Acute Alcohol Withdrawal

All patients need the following investigations:

U&E’s, Mg & PO4 LFT’s
FBC Clotting Screen
Blood glucose Folate / B12

Take an adequate history of current alcohol intake

Are there any Alcohol withdrawal symptoms/signs?

Anxiety/agitation/irritability Sweating
Tremor of hands, tongue, eyelids Tachycardia
Nausea/vomiting/retching Anorexia
Insomnia, Hallucinations Mild systolic hypertension
Fever, with or without infection

NO YES

Are any risk factors for progression Are there symptoms of autonomic over-activity?
to severe withdrawal present? (any Impaired attention Tachypnoea
ONE of the following) Paranoid ideas Marked anxiety
High alcohol intake (> 8 units/day) Systolic hypertension Insomnia
High levels of anxiety Profuse sweating Reversal of sleep pattern
Sweating Hallucinations / confusion
Wernicke’s encephalopathy
Hypoglycaemia
Insomnia
History of severe withdrawal (includes IF YES;
seizures/DTs) NO
either has or at risk of DTs
Hypokalaemia
Tachycardia
Concomitant use of other psychotropic
drugs
Respiratory alkalosis YES Obtain expert advice
Hypocalcaemia Administer IV Pabrinex high potency
Other psychiatric disorders (see opposite)
Poor physical health
Fever

Chlordiazepoxide regime prescribed on variable dose section and

NO vitamin supplementation should always be considered alongside this
regime see page 2
TIME DAY 1 DAY 2 DAY 3 DAY 4 DAY 5 DAY 6 DAY 7 DAY 8
No treatment necessary but
continue to monitor 08.00 20mg 20mg 20mg 20mg 10mg 10mg S

12.00 20mg 20mg 10mg 10mg 10mg T

DISCHARGE MEDICATION 18.00 20mg 20mg 10mg 10mg 10mg 10mg O

Chlordiazepoxide as a TTO should
NOT be considered until after 22.00 20mg 20mg 20mg 20mg 10mg 10mg 10mg P
discussion with a Consultant
AND THAT *Prescribe “PRN” chlordiazepoxide in addition 10-20mg up to 200mg total per
day. Adjust and titrate both regular and “PRN” doses according to response.
A suitable strong supportive home *If more than three doses are given PRN in a 24hour period refer to Doctor for
environment has been assessed. review of medication *REVIEW AND ASSESS DAILY
Consider referral to local alcohol
services (see opposite). *CAUTION: care in liver disease, respiratory depression, renal failure or aged more
than 70 years
 Management Algorithm for Vitamin Supplementation & Prevention and/or Treatment for
Wernicke’s Encephalopathy

Every patient prescribed Chlordiazepoxide-reducing regime should have:

One dose of Pabrinex HP ampoules (1 pair) –

administered IV once only in 100ml of 5% Dextrose over 30 minutes.
Dextrose can further deplete thiamine stores, precipitating Wernickes’-Korsakoff syndrome.

Are any ONE or more from the list below present?

Acute confusion Ophthalmoplegia
Decreased consciousness level Nystagmus
Memory disturbance Unexplained hypotension with hypothermia
Ataxia / unsteadiness

YES NO

Presume Wernicke’s
encephalopathy
Pabrinex HP amps 2 pairs (4
ampoules) IV TDS for 3 days
(given as above)
Then OD for 2- 3 days
Then Thiamine Oral 100mg
TDS for one week
Multivitamin (One a day) OD
Are there any further Risk Factors that suggest
Wernicke’s encephalopathy?
Intercurrent Illness Peripheral neuropathy
DTs/Treatment for DTs Drinking > 20units daily
Alcohol related seizures Recent diarrhoea/vomiting
IV Glucose infusion Signs of malnutrition
Significant weight loss Poor diet / Nil by Mouth
YES NO

Risk of Wernicke’s encephalopathy Thiamine 100mg

or Nil by Mouth TDS for one week
Multivitamin 1
tablet per day
Pabrinex HP 1 pair (2 ampoules) IV
OD for 3 days (given as above)
Then Thiamine Oral 100mg TDS
for one week
Multivitamin 1 tablet per day

Pyridoxine 20mg OD for 3 weeks has been shown to be beneficial with hepatic impairment
or evidence of neuropathy features e.g. deranged LFT’s, jaundice and hypoalbumaenia

DISCHARGE MEDICATION: Thiamine 100mg once a day (OD)

Multivitamin One per day (OD)
 Useful contacts:

• Local Alcohol Services:

• Plummer Court 0191 219 5600
• Gateshead Addiction Services 24/7 0191 443 6880
• Northumberland Addiction Centre 01670 396310

• North Eastern Council on Addictions (NECA) 0191 222 1262

• Social Services, Drug and Alcohol:

• Newcastle 0191 278 8100
• North Tyneside 0191 200 6847

•
Alcoholics Anonymous (AA) National Helpline

Al Anon (for family / friends support) } 0845 769 7555

Ratified by: Professor C P Day, Eilish Gilvarry

Preparation date: February 2004
Review date: February 2006