CHHS17/268

Canberra Hospital and Health ServicesClinical Guideline Medical Management of Alcohol Withdrawal Contents

Contents....................................................................................................................................1

Guideline Statement.................................................................................................................2

Scope........................................................................................................................................ 2

Section 1 – Alcohol Withdrawal................................................................................................2

Section 2 – Clinical Indicators for commencing an AWS...........................................................3

Section 3 – Guidance in the use of AWS...................................................................................3

Section 4 – History of alcohol withdrawal seizures...................................................................4

Section 5 – Indications for Transfer of people from AMC or DMHU to the Canberra Hospital. 5

Implementation........................................................................................................................ 6

Related Policies, Procedures, Guidelines and Legislation.........................................................6

References................................................................................................................................ 6

Definition of Terms...................................................................................................................7

Search Terms............................................................................................................................ 7

Attachments..............................................................................................................................7

Attachment 1 – Features of withdrawal................................................................................8

Attachment 2 – Alcohol Withdrawal Scale............................................................................9

Attachment 3 – Example of Medication Order Chart for PRN Diazepam............................11

Attachment 4 – Alcohol withdrawal regimes......................................................................12

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Guideline Statement

This guideline provides Canberra Hospital and Health Services (CHHS) Medical and Nursing staff guidance relating to the medical management of Alcohol Withdrawal including the following: Clinical indicators for commencing an assessment using the Alcohol Withdrawal Scale

(AWS); The use of the AWS score in conjunction with the medication order ; Indications for when advice is to be sought from the Alcohol and Drug Service (ADS)

Medical Officers and Consultation Liaison (CL) Circumstances under which people experiencing alcohol withdrawal must be transferred

from Alexander Maconochie Centre (AMC) or Dhulwa Mental Health Unit (DMHU).

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Scope

This clinical guideline is for use by all ACT Health medical and nursing staff including Consultation and Liaison (CL) nurses and Medical Officers from the Alcohol and Drug Service (ADS).

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Section 1 – Alcohol Withdrawal

Alcohol dependence or heavy alcohol consumption can often be unrecognised, particularly when a person is admitted to hospital for surgery or other reasons. Alcohol withdrawal can lead to seizures, hallucinations and severe withdrawal syndromes (previously called Delirium Tremens – the “DT’s”), that can be life threatening. It is important that clinicians are able to assess, recognise and respond to the symptoms of withdrawal so it can be treated early.

Alcohol withdrawal can start 6 to 12 hours after the last drink and can be independent from a Breath Alcohol Level (BAL) returning a positive reading.

The severity of alcohol withdrawal ranges from mild to moderate to severe. The early recognition and correct medical management of the initial, milder stages of withdrawal is crucial in preventing progression into the severe, life threatening stages. Seizures can occur at any time during withdrawal, but usually occur within the first 48 hours.

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Section 2 – Clinical Indicators for commencing an AWS

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The following are clinical indicators for commencing an AWS that clinicians should be aware of: A history of heavy drinking or alcohol dependence, and less than 10 days since the last

consumption of alcohol by a patient. A regular daily intake of 80 grams of alcohol for several months or weeks prior to

admission. A regular consumption of smaller amounts of alcohol in conjunction with significant

doses of other Central Nervous System (CNS) depressants, e.g. benzodiazepines. A history of previous episodes of alcohol withdrawal. A history of previous alcohol withdrawal seizures or other serious withdrawal symptoms. A current admission for an alcohol related reason. A previous history of an alcohol related condition e.g. alcoholic hepatitis, alcoholic

cardiomyopathy, pancreatitis, oesophageal varices, and liver disease. A characteristic physical appearance indicating harmful alcohol use, e.g. facial

vascularisation, signs of liver disease, e.g. ascites, jaundice, muscle wasting, spider naevi, palmar erythema etc.

Recent pathology results showing raised serum Gamma Glutamyl Transpeptidase (GGT) and/or raised mean cell volume (MCV). Note that these are non-specific and may be raised for a number of unrelated reasons

A history of/ or reported symptoms such as hypertension, anxiety, sleep disturbance, agitation, tremor, sweatiness, nausea/vomiting, or early morning retching, possibly due to alcohol withdrawal.

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Section 3 – Guidance in the use of AWS

The AWS form can be found on the Clinical Forms Register. Staff should always record the time of the last alcoholic drink, and the blood or breath alcohol reading at the time of admission. This will provide a more accurate diagnosis of any risk of withdrawal and its anticipated time of onset, and/or poly drug overdose or concurrent illness or injury.

The most systematic and useful way to measure the severity of withdrawal is to use a withdrawal scale. This provides a baseline against which changes in withdrawal severity may be measured over time thus avoiding both under and overdosing with benzodiazepines and other symptomatic medications for alcohol withdrawal syndromes.

The Alcohol Withdrawal Scale does not diagnose the alcohol withdrawal syndrome, but merely guides in the identification of symptoms indicative of the severity of an already diagnosed withdrawal syndrome. (Attachment 1)

The AWS is a 6 item scale for assessing the clinical course of alcohol withdrawal. The aim is to keep the AWS score less than 5. (Attachment 2)

Association between a medication dosage scale and AWS score

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The most commonly prescribed pharmacological treatment for alcohol withdrawal is Diazepam because it is long acting, there is a cross tolerance with alcohol and it has anti-convulsant properties. A potential risk is over sedation with benzodiazepines, but that is unusual and more often the dose of diazepam prescribed in the Hospital setting is inadequate to control withdrawal symptoms. Benzodiazepines are generally very safe drugs to use in these circumstances.

Diazepam 10-20mg (orally) should be prescribed in order to keep AWS score less than 5 (see attachment 3 for example medication order). If more than around 80 mg of Diazepam is required over 24 hours, a medical review is usually indicated. During normal business hours the ADS Medical officer should be consulted; after hours a medical review by the RMO/ Medical Registrar on call should be sought (see Alcohol Withdrawal regimes – Attachment 4).

People in the AMC with moderate to severe alcohol withdrawal should be reviewed by the AMC AOD Nurse (Monday to Friday) until alcohol withdrawal has stabilised. The AOD nurse will liaise with the Medical Officer or on-call Medical Officer (after hours) as required. Oversight of weekend treatment and care should be discussed with the Clinical Director, JHS.

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Section 4 – History of alcohol withdrawal seizures

Alert:Any seizure must be taken seriously and investigated for causes

People with a past history of alcohol withdrawal seizures should usually receive diazepam in a loading protocol i.e.: 10-20 mg hourly to 60mg in total (titrated to patients’ level of sedation). Staff should observe for over sedation.

Diazepam should only be withheld if signs of benzodiazepine intoxication or over-sedation is present.

Alcohol withdrawal management where Diazepam sedation is contraindicated:1. Acute or chronic liver disease

The advice of an ADS specialist medical officer is necessary It is essential to determine that the person is in withdrawal and not hepatic

encephalopathy as injudicious sedation may be dangerous Oxazepam may be preferable to Diazepam because it has a shorter half-life and it has

no active metabolites (15mg Oxazepam =5mg Diazepam).

2. Chronic airflow limitation The advice of an ADS specialist medical officer is necessary Diazepam should not be used if a patient has respiratory failure as it may worsen the

condition due to respiratory depression

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An Oxazepam regime e.g. 15-30mg prn, may be the choice in this instance as it has a shorter half-life

3. No oral intake (nil by mouth) Consult specialist medical officer for advice as to IV or IMI sedation

Indications for when advice/review should be sought from Alcohol and Drug Services At request of patient (D&A Consultation Liaison see patients in the Hospital on a daily

basis) If patient has received total 80mg diazepam in 24 hours for alcohol withdrawal, review

by at least the RMO is usually indicated (this is to ensure that it is alcohol withdrawal and not another medical condition being measured)

The patient is demonstrating symptoms of severe withdrawal A patient whose withdrawal syndrome is difficult to manage The patient suffers from liver disease If unsure of medication regime for alcohol withdrawal or loading dose regime for patient

with a history of seizures Patients with thiamine deficiency Patients with moderate to severe alcohol withdrawal should be reviewed by ADS CL

daily until alcohol withdrawal has stabilised (Refer to Attachment 1) During normal business hours the ADS Medical officer should be consulted; after hours a

medical review by the RMO/ Medical Registrar on call should be sought

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Section 5 – Indications for Transfer of people from AMC or DMHU to the Canberra Hospital

While it is often possible to clinically manage detainees in alcohol withdrawal within the AMC or DMHU, there are numerous circumstances when it is inappropriate to do so, and transfer to the Canberra Hospital is required. These circumstances include: Alcohol withdrawal management where Diazepam sedation is contraindicated Acute or chronic decompensated liver disease Respiratory failure No oral intake for a prolonged period, with assessed danger of re-feeding complications Excessive sedation, possibly from diazepam over-dosing If patient has received a total of 100mg diazepam in 24 hours The person is demonstrating symptoms of severe withdrawal A person whose withdrawal syndrome is difficult to manage If unsure of medication regime for alcohol withdrawal or loading dose regime for patient

with a history of seizures, or Patients with signs/symptoms of clinical thiamine deficiency (peripheral neuropathy,

Wernicke-Korsakoff syndrome).

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Implementation

This guideline will be communicated to all staff through an all staff DDG CHHS email alert and through line managers.

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Related Policies, Procedures, Guidelines and Legislation

Procedures Emergency Department and Mental Health Interface Operational Procedure Medication Handling Policy

Guidelines National Safety and Quality Healthcare Services Standards 2012 Mental Health Standards 2010

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References

1. Flinders University and Drug & Alcohol Services Council (2003). Alcohol, Tobacco & other Drugs. Guidelines for Nurses & Midwives: Clinical Guidelines. Flinders University and Drug & Alcohol Services Council, South Australia.

2. NSW Health Detoxification Clinical Practice Guidelines 2000-2003,www.health.nsw.gov.au/...health/.../detoxification clinical practice guidelines.pdf, viewed Friday 18 November 2011.

3. New South Wales (NSW) Health (2007). NSW Drug and Alcohol Withdrawal Clinical Practice Guidelines. New South Wales Department of Health, North Sydney.

4. Turning Point (2007). Vocational and Technical Education Training Packages Student Notes, Turning Point Alcohol and Drug centre, Fitzroy, Victoria.

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Definition of Terms

Alcohol Withdrawal Scale (AWS): a 7 item scale with a potential maximum score of 27, used to assess levels of alcohol withdrawal and ‘symptom-triggered’ prn sedation.

Diazepam: a benzodiazepine in the sedative-hypnotic group of drugs which have a general depressant effect that increases with the dose.

Alcohol Withdrawal Seizures: occurring early (usually 7–24 hours after the last drink). They are grand mal in type (i.e. generalised, not focal) and usually (though not always) occur as a single episode.

BAL: breath alcohol level

Polydrug overdose: Polydrug use is when a person uses more than one type of drug – either at the same time or at different times. Polydrug use can lead to more problems than using just one type of drug. For example, it can increase the chances of overdose.

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Search Terms

Alcohol, Withdrawal, Consultation and Liaison, Seizures, AWS, BAL

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Attachments

Attachment 1 – Features of withdrawalAttachment 2 – Alcohol Withdrawal ScaleAttachment 3 – Example of Medication Order Chart for PRN DiazepamAttachment 4 – Alcohol withdrawal regimes

Disclaimer: This document has been developed by Health Directorate, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

(to be completed by the HCID Policy Team)Date Amended Section Amended Approved ByEg: 17 August 2014 Section 1 ED/CHHSPC Chair

Attachment 1 – Features of withdrawal

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Mild withdrawal Mild rise in temperature eg 37 degrees Celsius Mild anxiety Slight tremor Mild sweating Nausea and vomiting Headaches Mild hypertension Tachycardia

Moderate withdrawal Mild rise in temperature Moderate anxiety Moderate sweating Nausea and vomiting Tremor Restlessness/agitation Diarrhoea Mild to moderate hypertension Insomnia

Severe withdrawal Acute anxiety Agitation Convulsions/seizures Dehydration Excessive sweating Marked tremor Tachycardia Hypertension Nausea and vomiting Diarrhoea Disorientation/confusion Fever Hallucinations Hypersensitivity to stimulation

Note: The usual course of withdrawal is 5-7 days

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Attachment 2 – Alcohol Withdrawal Scale

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Sample

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Attachment 3 – Example of Medication Order Chart for PRN Diazepam

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Sample

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Attachment 4 – Alcohol withdrawal regimes

Mild withdrawal predicted – Diazepam 10-20mg prn to keep AWS less than 5 when there is: No other likely medical condition that may complicate or mimic withdrawal No history of withdrawal seizure Daily intake less than 80 grams (60 grams in women) Daily intake greater than 80 grams (60 grams in women) and the person is under 30

years old History of previous mild withdrawal syndrome

Significant alcohol withdrawal predicted – Diazepam loading is recommended (total 60mg) plus e.g. Diazepam 10-20mg to keep AWS less than 5 when there is: History of withdrawal seizures Past history of severe withdrawal

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