A 33-year-old male was admitted to the emergency department after having 2 alcohol withdrawal seizures. He had been drinking 30U alcohol per day for many years and over the previous week he had been trying to reduce his alcohol intake without any support.
He had previously been admitted with a similar episode 3 weeks earlier and admitted under the care of the medics.
On arrival in the ED he had been a marked tremor, tachycardia, confusion and nystagmus but no sweating or anxiety. He had been given 2 vials of pabrinex during his initial triage.
A full clinical examination was performed and a decision was made to admit him to hospital due to risk of further seizures related to acute alcohol withdrawal.
For such patients, the use of Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA-Ar) may provide a useful way of determining the need for pharmacological treatment for each patient presenting with acute alcohol withdrawal.
Continued hazardous and harmful drinking can result in alcohol dependence. An abrupt reduction in alcohol intake in a person who has been drinking excessively for a prolonged period of time may result in the development of an alcohol withdrawal syndrome including seizures (and delirium tremens) and Wernicke’s encephalopathy (National Institute for Health and Care Excellence – NICE (2010).
Wernicke’s encephalopathy refers to the presence of neurological symptoms (nystagmus, ophthalmoplegia, ataxia and confusion) that is caused by biochemical lesions of the central nervous system after a total exhaustion of the B-vitamin reserves, in particular thiamine (Sechi & Serra 2007). The body only has 2-3 weeks of thiamine reserves, which are readily exhausted without intake and depletion can occur much more rapidly in chronic inflammatory states and diabetes (Sechi & Serra 2007). This is the rationale for the need for immediate pabrinex (parental B-vitamin administration).
It should be remembered that it is not only alcoholics who may develop this as any condition of unbalanced nutrition can lead to thiamine deficiency e.g. cancer or gastrointestinal disorders associated with recurrent vomiting (Sechi & Serra 2007).
Alcohol withdrawal syndrome requires immediate treatment to avoid the development of complications e.g. seizures and delirium tremens. The use of assessment tools e.g. CIWA-Ar scale maybe useful as an adjunct to clinical judgment. CIWA-Ar score was developed by Sullivan et al in 1989. It utilises a number of questions and generates a maximum score of 67. Pharmacological treatment for withdrawal is not indicated if the score is less than 10 and clinical judgement is required if the patient scores between 10 and 20 (Sullivan et al 1989). For patients scoring more than 20 it is appropriate to give pharmacological treatment (Sullivan et al 1989).
Typical symptoms which maybe encountered in alcohol withdrawal syndrome (and feature on the CIWA-Ar scale) include nausea, tremor, sweating, anxiety, agitation and tactile, auditory or visual disturbances (NICE 2010).
Benzodiazepines are the mainstay of treatment and these prevent progression from minor withdrawal symptoms to major ones e.g. seizures and delirium tremens (NICE 2010). Diazepam, lorazepam and chlordiazepoxide are most frequently used due to a longer half life and exert their effect via stimulation of gamma-aminobutyric acid (GABA) receptors, causing a decrease in neuronal activity and relative sedation (Mehdi 2012).
In the emergency department initial treatment with diazepam 5-10mgs or chlordiazepoxide 10-30mgs should be offered every 4-6 hours (Wyatt et al 2012).
This case has demonstrated the reasons for the pharmacological treatment, which are given to patients presenting with acute alcohol withdrawal and the potential for Wernicke’s encephalopathy. It has reinforced the need to expedite the delivery of these medications when patients present, to prevent deterioration.
For patients at risk of acute alcohol withdrawal syndrome the use of the CIWA-Ar scale provides an evidence based approach and rationale for the provision of pharmacological treatments.
Driscoll, J. (2007) Practicing clinical supervision: a reflective approach for healthcare professionals (2nd edition). Elsevier. Edinburgh.
Mehdi, T. (2012) Benzodiazepines revisited. British Journal of Medical Practitioners. Volume 5, Number 1, a501. Available online from: http://www.bjmp.org/content/benzodiazepines-revisited (Last accessed 5/9/15).
National Institute for Health and Care Excellence. (2010) Alcohol-use disorders: Diagnosis and clinical management of alcohol-related physical complications. Found at: https://www.nice.org.uk/guidance/cg100 (Last accessed 5/9/15).
Sechi, G & Serra, A. (2007) Wernicke’s encephalopathy: new clinical settings and recent advances in diagnosis and management. Lancet Neurology. Volume 6, pp442-455.
Sullivan, J. T., Sykora, K., Schneiderman, J., Naranjo, C. A & Sellers, E. M. (1989) Assessment of alcohol withdrawal: the revised clinical institute withdrawal assessment for alcohol scale (CIWA-Ar). British Journal of Addiction. Volume 84, pp1353-1357.
Wyatt, J., Illingworth, R., Graham, C & Hogg, K. (2012) Oxford handbook of emergency medicine (4th edition). Oxford University press. Oxford.