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Acute Alcohol Withdrawal Symptom Management
Acute Alcohol Withdrawal Symptom Management
Olivia J. Warner
The Community College of Baltimore County
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Acute Alcohol Withdrawal Symptom Management
What is the best way to manage acute alcohol withdrawal syndrome? It is
important for all nurses to know the answer to this question as this syndrome can affect
patients anywhere in the hospital. A patient at Northwest Hospital was admitted to the
oncology floor to be treated for acute alcohol withdrawal syndrome after presenting with
tachycardia in the emergency department. This situation highlights the need for nurses
in all units to be aware of current evidence-based practice regarding the management of
acute alcohol withdrawal syndrome in order to prevent serious and possibly fatal
complications, including delirium tremens and Warnicke-Korsakoff Syndrome.
The first step in managing acute alcohol withdrawal syndrome is to be able to
recognize patients who are at risk for developing the syndrome. Northwest Hospital
provides nurses with the four question CAGE Tool; if the patient provides two or more
affirmative answers, then the nurse needs to continue assessing the patient’s drinking
history for signs of alcohol dependence. The patient who presented in the emergency
department with tachycardia was thoroughly screened using the CAGE Tool along with
further questioning. The emergency department acquired a detailed drinking history for
the patient and found that she was at risk for acute alcohol withdrawal syndrome and
was admitted to the hospital. Because of this screening, she was quickly started on
medications, including benzodiazepines and vitamins, in order to prevent her alcohol
withdrawal symptoms from progressing to deadly complications. The patient’s alcohol
withdrawal induced tachycardia resolved and, after about 24 hours of being
asymptomatic, she was discharged in order to attend an inpatient rehabilitation center
for alcohol addiction.
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Acute Alcohol Withdrawal Symptom Management
Compared to front loading or fixed-dose benzodiazepine dosing, symptom-
triggered dosage significantly decreases both the duration of treatment and the total
benzodiazepine usage during acute alcohol withdrawal (“Benzodiazepines are the
Mainstay,” 2014). In order to provide patients with symptom-triggered dosage of
benzodiazepines, nurses must assess the patients using an objective withdrawal
assessment scale. The provider will then calculate the benzodiazepine dosage based
on the individual patient’s score and whether or not it is improving. Northwest Hospital
uses the Modified Clinical Institute of Withdrawal Assessment of Alcohol (CIWA-Ar) in
order to assign a numeric value to the patient’s level of alcohol withdrawal with higher
numbers indicating more severe withdrawal symptoms. Registered nurses are
responsible for administering the CIWA-Ar every two hours for patients who score 12 or
higher and every four hours for patients who score below 12; assessments are
discontinued once the patient scores below a 6 for 24 hours (Northwest Hospital, 2015).
Symptom-triggered dosage based on the CIWA-Ar prevents patients from receiving
unnecessarily high levels of benzodiazepines and, therefore, decreases the patients’
risk of over-sedation and physical dependence.
Delirium tremens is a life threatening form of alcohol withdrawal resulting in
severe and rapidly progressing mental and nervous system changes. Symptoms of
delirium tremens can include hallucinations, irregular heartbeat and tonic-clonic
seizures. Early intervention in delirium tremens is important as it can rapidly lead to a
fatality. According to Northwest Hospital (2015), registered nurses should immediately
notify a provider if a patient develops symptoms of delirium tremens and administer the
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Acute Alcohol Withdrawal Symptom Management
antipsychotic drug haloperidol in order to to sedate and decrease agitation of the
patient. Providing prophylactic nursing interventions before the patient develops delirium
tremens could be a hospital policy in the near future. New research has shown that a
low platelet count and high blood level of homocysteine are predictors of delirium
tremens and that lowering blood homocysteine by administering vitamins B12, B6
(pyridoxine), and folic acid could prevent the patient from ever developing delirium
tremens (Kim, Kim, Bae, Park, & Kim, 2015). Performing a simple venous blood draw to
detect the risk of a potentially fatal alcohol withdrawal syndrome and prevent it from
happening would be significant improvement in policy.
Warnicke’s encephalopathy and Korsakoff’s psychosis are serious syndromes
related to alcohol abuse and often occur together as Warnicke-Korsakoff syndrome.
Warnicke’s encephalopathy can cause ataxia, nystagmus, altered mental status and
can progress to a coma or death. Korsakoff’s psychosis causes severe brain damage
that can cause hallucinations, severe memory loss and the inability to form new
memories. These conditions typically transpire at the same time because they are both
caused by a vitamin B1 (thiamine) deficiency. According to the World Health
Organization (2012), all patients who are experiencing alcohol withdrawal should
receive oral thiamine and those at high risk for Warnicke’s encephalopathy should
receive vitamin B1 parentally for three days. Northwest Hospital policy states that all
patients experiencing acute alcohol withdrawal should be given 100 milligrams of
vitamin B1 daily throughout the withdrawal phase in order to prevent Warnicke-
Korsakoff syndrome (Northwest Hospital, 2015).
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Acute Alcohol Withdrawal Symptom Management
The policy and procedure for acute alcohol withdrawal symptom management at
Northwest Hospital is closely aligned with current evidence-based practice. Quick
screenings of patients upon admission quickly reveal who might be at risk for
developing alcohol withdrawal symptoms during a hospital stay. This screening can also
reveal the cause behind the symptom that brought them in, for example, the patient at
Northwest Hospital who arrived at the emergency department complaining of
tachycardia. After the CAGE Tool questionnaire raised suspicions of alcohol abuse, the
emergency department staff asked for more details and discovered a long history of
alcoholism. Once the patient is identified as having a risk for developing acute alcohol
withdrawal symptoms, they are assessed using the detailed CIWA-Ar which is one of
the most thorough assessments of its kind. The use of the CIWA-Ar to determine
symptom-triggered benzodiazepine dosage is backed up by new research and has
already been implemented at Northwest Hospital. Although the policy for delirium
tremens does not include the new research for venous blood screening, it is likely due
to the need for repeat studies with larger sample sizes in order to verify the validity of
the results. Overall, Northwest Hospital does a good job implementing current evidence-
based practice into their patient care policies and procedures regarding acute alcohol
management syndrome.
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Acute Alcohol Withdrawal Symptom Management
References
Benzodiazepines are the mainstay of treatment for acute alcohol withdrawal syndrome.
(2014). Drugs & Therapy Perspectives, 30, 395-398.
http://dx.doi.org/10.1007/s40267-014-0152-2
This peer-reviewed journal is a concise, authoritative aid to drug decision-making
intended for pharmacists and physicians who need to make formulary and
prescribing decisions and includes the latest peer-reviewed drug knowledge.
Kim, D. W., Kim, H. K., Bae, E.-K., Park, S.-H., & Kim, K. K. (2015). Clinical predictors
for delirium tremens in patients with alcohol withdrawal seizures. American Journal
of Emergency Medicine, 33, 701-704. http://dx.doi.org/10.1016/j.ajem.2015.02.030
This peer-reviewed journal focuses on emergency medicine and includes
information to help increase the ability to understand, recognize and treat
emergency conditions.
Management of alcohol withdrawal. (2012). Retrieved May 10, 2016, from
http://www.who.int/mental_health/mhgap/evidence/alcohol/q2/en/
This webpage was created by the World Health Organization as one of their
many educational webpages addressing health topics.
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Acute Alcohol Withdrawal Symptom Management
Northwest Hospital. (2015) Acute alcohol withdrawal symptom management (nursing).
(Policy Number A-2). Randallstown, MD.
This is a hospital policy for Northwest Hospital that provides guidelines for nurses
in the management of acute alcohol withdrawal symptoms in patients.
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