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Acute Alcohol Withdrawal Symptom Management


Olivia J. Warner

The Community College of Baltimore County

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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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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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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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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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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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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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