Alcohol withdrawal syndrome is a set of clinical features that can occur when a person reduces or abruptly stops alcohol consumption after long periods of use.
The pathophysiology of alcohol withdrawal is incompletely understood. Sudden cessation of or a significant reduction in alcohol consumption triggers an acute neurotransmitter imbalance with rapid decline in inhibitory GABA activity and increased excitatory glutamate/NMDA activity, resulting in overall CNS hyperactivity and reduced threshold for seizures.
Symptoms of alcohol withdrawal typically manifest when a person stops or decreases their alcohol consumption after a prolonged period of drinking. Mild symptoms often begin to emerge within a few hours of the last alcoholic beverage.
Alcohol withdrawal can be dangerous due to its potential to cause severe and potentially life-threatening symptoms, known as delirium tremens (DTs)
Mild withdrawal typically occurs within 24 hours of the last drink and is characterized by the following:
- Tremors
- Insomnia
- Anxiety
- Hyperreflexia
- Diaphoresis
- GI upset
Moderate withdrawal usually occurs 24-36 hours after the cessation of alcohol intake and includes the following:
- Intense anxiety
- Tremors
- Insomnia
Severe withdrawal usually occurs more than 48 hours after a cessation or decrease in alcohol consumption and is characterized by the following:
- Profound alteration of sensory nervous system:
- Disorientation
- Agitation
- Hallucinations
- Severe autonomic hyperactivity:
- Tremulousness
- Tachycardia
- Tachypnea
- Hyperthermia
- Diaphoresis
Seizures in patients experiencing alcohol withdrawal
Alcohol-withdrawal seizures are usually:
- Brief (no longer than 30 to 60 seconds)
- Generalised
- Seen in people with alcohol dependence with a long history of high alcohol intake
- Evident early in withdrawal
Tachycardia, sweating and agitation after a seizure support a diagnosis of a withdrawal seizure; a calm, drowsy postictal patient is likely to have a comorbid seizure disorder.
Delirium in alcohol withdrawal
In patients with alcohol dependence, common risk factors for delirium are acquired brain injury, cognitive impairment; including dementia, and acute medical or surgical illness. Delirium tremens (DT's) are rarely seen, probably because of the widespread use of benzodiazepine treatment to manage alcohol withdrawal.
DT's are the most severe manifestation of alcohol withdrawal and are characterised by:
- Generalised tremors
- Diaphoresis
- Fluctuation levels of agitation, hallucinations (usually tactile)
- Disorientation and impaired attention
Delirium tremens is usually identified after 48 to 72 hours of more severe alcohol withdrawal in the setting of recent acute illness or surgery. Delirium tremens is a medical emergency that always requires hospitalisation and, if inadequately treated, carries mortality risk, mainly from heart failure.
| Alcohol withdrawal risk stratification | ||
|---|---|---|
| Orientation | 0 – Oriented | The patient is fully oriented in time, place and person |
| 1 - Disoriented | Disoriented but cooperative | |
| 2 - Uncooperative | Disoriented but uncooperative | |
| Agitation / Anxiety | 0 - Calm | Rests normally |
| 1 - Anxious | Appears anxious | |
| 2 - Panicky | Appears very agitated all the time | |
| Hallucination | 0 - None | No evidence of hallucinations |
| 1 – Can Dissuade | Distortions of real objects or hallucinations, but accepted as not real when pointed out | |
| 2 – Cant Dissuade | Believes the hallucinations are real and cannot be reassured | |
| Perspiration | 0 – Nil | No abnormal sweating |
| 1 – Moist/Wet | Mild to moderate perspiration | |
| 2 - Soaking | Soaking sweat | |
| Tremor | 0 – No Tremor | No tremor |
| 1 - With intentional movements | Tremor when moving hands and arms | |
| 2 – Tremor at rest | Constant tremor of arms, even at rest | |
| Temperature | 0 – 37.5ºC | Tympanic |
| 1 – 37.6ºC – 38.5ºC | Tympanic | |
| 2 - >38.5ºC | Tympanic | |
A score of ≥ 1 should be escalated to ED triage for review.
* Hallucination = Appearance of totally new objects or perception not related to any new object
Predictors of severe or complicated alcohol withdrawal
- A history of moderate to severe alcohol withdrawal, especially multiple episodes
- Current acute medical or surgical illness
- Current acute mental illness, such as anxiety [NB1]
- Severe comorbidity that might be destabilised (e.g. chronic liver disease, chronic obstructive pulmonary disease), seizure disorder or suspected lowered seizure threshold
- History of memory blackouts (acute memory loss during alcohol intoxication)
- Cognitive impairment
- Early-morning drinking to alleviate withdrawal symptoms (anxiety, nausea, tremor
- Use of more than one substance (polysubstance use), particularly benzodiazepines, but also opioids, stimulants
- In older patients or those with polysubstance use, an intake of more than 8 standard drinks of alcohol per day [NB2]
NB1: Alcohol withdrawal in a person with an anxiety disorder causes escalation in anxiety levels. Many of the signs monitored on an alcohol withdrawal scale are also exacerbated by anxiety (tremor, tachycardia, sweating). The usual duration of the acute alcohol withdrawal phase is 2 to 3 days. Anxiety that persists longer is often misinterpreted as persisting acute withdrawal, leading to prolonged use of the alcohol withdrawal scale and excessive administration of diazepam.
NB2: In other patients, the feature of early-morning drinking to alleviate withdrawal is more relevant than the number of drinks per day.
- Primary Survey
- Position patient appropriately Lateral position if unresponsive (use left lateral position for pregnant women)
- Full Vital Signs Survey, particularly GCS, BGL, Pulse Oximetry and Temperature
- Consider oxygen therapy if indicated
- Manage for seizures if they occur
- Escalate alcohol withdrawal risk stratification score to ED triage
- As per Primary Care guidelines
- Manage as per primary care advice
- Consider the need for cardiac monitoring
- Consider 12 lead ECG in severe alcohol withdrawal presentation
- Consider need for Vascular access
- As per Advanced Care guidelines
Providing an alcohol withdrawal risk stratification score to ED triage will assist the hospital identify the need for supportive care.
| Settings | |
|---|---|
| Extended Care: | |
| Colour assist: | |
Wood, E., Albarqouni, L., Tkachuk, S., Green, C. J., Ahamad, K., Nolan, S., McLean, M., & Klimas, J. (2018, August 28). Will this hospitalized patient develop severe alcohol withdrawal syndrome?: The Rational Clinical Examination Systematic Review. JAMA. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6905615/
SA Health. Alcohol withdrawal management.
https://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/clinical+resources/clinical+programs+and+practice+guidelines/substance+misuse+and+dependence/substance+withdrawal+management/alcohol+withdrawal+management
Nathanael J McKeown, D. (2022, July 13). Withdrawal syndromes clinical presentation. History, Physical Examination. https://emedicine.medscape.com/article/819502-clinical
Therapeutic Guidelines. (n.d.). https://tgldcdp.tg.org.au/viewTopic?etgAccess=true&guidelinePage=Addiction+Medicine&topicfile=alcohol-drug-problems&guidelinename=auto§ionId=c_AMG_Alcohol-withdrawal_topic_11#c_AMG_Alcohol-withdrawal_topic_11
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