Alcohol in Emergency Medicine

Introduction

• Alcohol misuse contributes to 20-25% of all hospital admissions and is a risk factor for many serious conditions including cancers, heart disease, stroke, accidents and suicide
• In the general hospital setting, alcohol misuse is often undetected with up to 30% of inpatients demonstrating evidence of 'hazardous drinking' when systematically screened. 
• Simple advice from Doctors can effect a significant reduction in alcohol intake
• Early detection and appropriate management of alcohol withdrawal syndrome usually ensures an uneventful withdrawal
• Serious complications (i.e. seizures, delirium tremens, Wernicke-Korsakoff syndrome) do occur and these complications of withdrawal carry a significant associated morbidity and mortality risk

Definitions

1 unit (10g) of alcohol is contained in:

• A 1/2 pint of normal strength beer, lager, cider
• A quarter pint of extra strong beer, lager, cider
• A small glass (125ml) of wine
• A single pub measure of spirits

Please remember a UK unit = 8g, an Irish unit = 10g of pure alcohol.

'Low risk' drinking:

• ♀: < 11 standard drinks (110g pure alcohol) spread out over the week, with at least two alcohol-free days
• ♂: < 17 standard drinks (170g pure alcohol) spread out over the week, with at least two alcohol-free days

Regular weekly consumption of more than 21 UNITS (in ♀) or 35 UNITS (in ♂) will result in some form of physical harm.

Working out alcohol consumption:

Number of units in one litre of any drink is the percentage alcohol (v/v) "strength" quoted. So..

• 500 mls (1/2 litre) of 8% lager contains 4 units
• 8th of litre (125 mls) of wine (12%) contains 1.5 units

Driving

Please note regarding alcohol intake and driving limits: DrinkAware

• Individual's metabolism, time and speed of ingestion and many other factors vary
• It is impossible to estimate blood alcohol levels for a given intake
• Any alcohol impairs ability to drive so there is no risk-free level of alcohol consumption
• Current Irish drink-driving limit is a BAC of 0.05. For professional, learner and novice drivers the limit is 0.02. Most people will have a BAC of 0.02 to 0.05 after one standard drink
• Novice/young drinkers are incapable of coping with even the simplest of driving manoeuvres after consuming just one unit of alcohol

Determining the extent of the alcohol misuse

• Establish whether 'hazardous drinking' or 'alcohol dependent' using an alcohol screening questionnaire
• Consider biological markers of alcohol problems
• MCV, gamma GT, CHO-deficient transferrin

Alcohol withdrawal syndrome?

Withdrawal symptoms are variable in intensity and usually occur within 24 hours of admission. Symptoms include autonomic excitation (i.e. anxiety, tremor, sweating, tachycardia) and agitation (i.e. 'must leave hospital', irritable, insomnia). The condition is potentially serious as complications have a significant attendant morbidity and mortality.

Severe alcohol withdrawal may be complicated by delirium, psychotic symptoms (delusions, hallucinations), seizures and the Wernicke-Korsakoff Syndrome.

Drowsiness is not a feature of alcohol withdrawal!

If drowsy - consider other causes of drowsiness (e.g. sepsis, hypoxaemia, hypoglycaemia, hypo-/hyper-natraemia, medication (sedation, analgesia), myocardial infarction, liver failure, renal failure, intracerebral causes.

Assessing the severity of alcohol withdrawal

• Use the CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol-revised version)
• This scale has 10 Items: 1) Nausea, 2) Tremor, 3) Sweats, 4) Anxiety, 5) Agitation, 6) Tactile disturbance, 7) Auditory disturbance, 8) Visual disturbance, 9) Headache and fullness in the head, 10) Disorientation and clouding of sensorium
• Mild withdrawal CIWA-Ar <10, Moderate withdrawal CIWA-Ar 10-20, Severe withdrawal CIWA-Ar >20

What are the major complications of alcohol withdrawal?

a) Delirium Tremens

• Characterised by confusion, inattention, irritability, marked agitation, insomnia and psychotic symptoms (vivid hallucinations (usually visual) and delusions)
• Delirium Tremens is often preceded by other signs of alcohol withdrawal (see above) and seizures. 
• Typically, long history of heavy alcohol use (>10 units per day over >5 years)
• Onset of delirium is typically on the third or fourth day of abstinence:
  • Contrast with tremulousness, perceptual disturbance (3-12 hours) and seizures (12 - 48 hours) all of which typically, occur earlier following cessation of alcohol. 
• Delirium Tremens is a medical emergency requiring medical inpatient admission and has a considerable mortality rate
• Co-morbidity of medical illness is common in these patients

b) Wernicke-Korsakoff syndrome

c) Seizures

• Seizures may be precipitated by alcohol in patients with established epilepsy
• First seizure requires urgent CT scanning (See alcohol seizure section)
• "Rum" fits are followed by delirium tremens in 30%

Management of alcohol problems

This depends on the extent of the problem i.e. whether the patient has hazardous drinking or alcohol dependency.

Hazardous Drinking but not Alcohol Dependent

1. Oral vitamin replacement for the duration drinking continues
2. Assess whether accompanying psychiatric disorder / substance misuse disorder - ? contact Liaison Psych Reg (Bleep 771/772) or On-call Psych Reg (Bleep 216)
3. Assess motivation for change and treat accordingly:
   • Not motivated: give advice, information on help lines/support (see Appendix), inform GP
   • Motivated: refer to Alcohol Treatment services (see Appendix) and give information on help lines/support, inform GP

Alcohol Dependent or Acute Alcohol Withdrawal

Acute Management:

1. Assessment and pharmacological treatment of alcohol withdrawal, prevention and/or treatment of complications (delirium tremens, seizures, Wernicke-Korsakoff syndrome)
2. Assessment and treatment of medical co-morbidity
3. Assessment and treatment of acute psychiatric co-morbidity. Consider contacting Liaison Psych Reg (Bleep 771/772) or On-call Psych Reg (Bleep 216)

Non-acute management:

1. Oral vitamin replacement for the duration drinking continues
2. Assess whether accompanying psychiatric disorder / substance misuse disorder
3. Consider contacting Liaison Psych Reg (Bleep 215) or On-call Psych Reg (Bleep 216)
4. Assess motivation for change and treat accordingly:
   1. Not motivated: give advice, information on help lines/support (see Appendix), inform GP
   2. Motivated: refer to Alcohol Treatment services (see Appendix) and give information on help lines/support, inform GP

Pharmacological Treatment of Alcohol Withdrawal and Delirium Tremens

When to treat?

• For patients in the CDU, treat with CIWA -Ar Score > 10-15
• Prevention better than cure
• If drinking > 10 units per day, or history of previous DTs, consider treatment with benzodiazepines
• Be wary of dehydration, hypoglycaemia, delirium caused by infective cause, head injury
• In hepatic failure seek gastroenterology opinion (See algorithm)

What drugs to use

• Benzodiazepines are drugs of choice for treatment of alcohol withdrawal
• The choice of benzodiazepine depends on presence or absence of chronic liver disease
• Chlormethiazole is not recommended
• No more than 5 days of reducing doses of benzodiazepine are required.
• Vitamins are given for the prevention and/or treatment of Wernicke-Korsakoff Syndrome
• Antipsychotic drugs are used as adjuvant treatment for agitated patients with psychotic symptoms usually as part of delirium tremens
• Anticonvulsants may be used in very selected patients

How to monitor

• Regular BP, HR, T°, Level of alertness, Severity of withdrawal symptoms (using CIWA-Ar), Signs of delirium
• Base management on severity of withdrawal symptoms in previous 24 hours
• Dosage adjustment is important especially during the first 48 hours following cessation of alcohol
• Medical review every day by medical staff

Algorithm

Chlordiazepoxide and Lorazepam reducing regime

In very agitated patients give parenteral lorazepam if necessary. Avoid IV diazepam in patients with chronic liver disease.

Patients attending with alcohol problems - General principles

1. Most importantly - is the patient suffering from a "medical" condition inducing them to stop drinking (classically subdural haematoma, pancreatitis, sepsis, Wernicke's), Alcohol and fitting section here
2. If the patient is so intoxicated and suffering from significant withdrawal that there is a serious risk to life then intervention is necessary
3. As with illicit drug use, patients with incipient DTs or withdrawal from alcohol may be in crisis and may be in a position to make a positive decision about their alcohol intake. At any one time 5% of recidivistic alcoholics are converting to abstinence. Doctors should always be on the look out for getting recidivistic drinkers to join the 5% "band wagon"
4. Why are they attending - have they been brought, are they aware of their attendance (or so intoxicated so as not to know where they are), are they with drawing or have they the DTs?

Antipsychotic Drugs

• Patients with any features of visual/auditory/tactile hallucinations or other psychotic symptoms may require short-term adjuvant treatment with an antipsychotic drug (e.g. haloperidol)
• Patients with no evidence of Liver Failure: use Haloperidol 1-5mg orally or IM. Repeat 4hourly if required. Maximum 30mg po or 18mg im /24hr
• Patients with evidence of Chronic Liver disease: use Haloperidol 0.5mg orally or IM.Repeat at two hourly intervals. Maximum 2mg/ 24 hours

Anticonvulsants

Anticonvulsants are of extreme doubtful value. Traditional regimens have included:

• Past History of more than one withdrawal seizure - CARBAMAZEPINE 200mg bd during detoxification
• Isolated seizure during withdrawal - continue standard regimen
• If more than one seizure during withdrawal - In addition to existing benzodiazepine give Lorazepam 2mg IV as a single dose
• If seizing continues seek specialist advice - is there another cause (e.g. SDH) - Consider PHENYTOIN loading and maintenance

Referral to Drug and Alcohol Services

Experience suggests that there is little or no point in referral to any service offering help with alcohol problems unless the patient, when sober agrees to the referral and seems motivated to change. Pressure is often brought to bear from concerned relatives (especially partners) - be wary of making referrals on this basis alone. If it is the impression of the referring clinician that the problem is entirely one of substance misuse rather than any other mental disorder, and the patient seems genuinely motivated to change, then the clinician may refer directly to the alcohol treatment service. In the intervening period prior to being assessed by the drug and alcohol service, patients may find it useful to contact a variety of help lines, the details of which are available below. Patients with alcohol and drug problems can be referred by any clinician to:

Support contact information

Which patients in alcohol withdrawal to admit from the ED

1. MILD WITHDRAWAL (CIWA-Ar scale score <10) cases do not normally require admission unless for other reasons (i.e. medical or psychiatric morbidity)
2. MODERATE WITHDRAWAL (CIWA-Ar scale score 10-20) cases do not normally require admission. Consider admitting the following: first presentation, socially vulnerable, history of seizures or significant liver disease, other reasons (i.e. medical or psychiatric morbidity)
3. SEVERE WITHDRAWAL (CIWA-Ar scale score >20) cases should all be admitted medically given risks of complicated withdrawal, making early contact with Liaison Psychiatry (Bleep 771/772) or on-call Psychiatry (Bleep 216)