QuestionSBA
QuestionChoice
This may well be done, however, initiating a benzodiazepine should be done in the first instance by the medical team.
10017254
d
Refer to liasion psychiatry team
QuestionChoice
This is correct. This is a case of alcohol withdrawal and delirium tremens with common symptoms including formication (feeling like insects are crawling on your skin), visual hallucinations (possibly of the insects), diaphoresis, confusion and a coarse tremor.
10017251
a
Chlordiazepoxide
QuestionChoice
Lithium toxicity may well cause a similar coarse tremor, confusion and diaphoresis however is unlikely to cause visual hallucinations and formication. In any case, lithium levels would be required before stopping or withholding lithium.
10017252
b
Discontinue lithium
QuestionChoice
This has no role in the acute treatment of alcohol withdrawal and delirium tremens which typically includes benzodiazepines and B vitamins in the first instance. Disulfiram may help with a later stage to quit drinking due to its role in aversion therapy.
10017255
e
Initiate disulfiram
QuestionChoice
Lithium toxicity may well cause a similar coarse tremor, confusion and diaphoresis however is unlikely to cause visual hallucinations and formication. In any case, lithium levels would be required before stopping or withholding lithium. Haemodialysis may used to treat severe cases of lithium toxicity.
10017253
c
Initiate haemodialysis
QuestionComment
can this also be lithium toxicity?
60199
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subscriber
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# Summary

Harmful alcohol consumption is very common in the UK, and prolonged periods of alcohol excess can lead to dependence. An important complication of alcohol dependence is acute withdrawal, when patients abruptly stop drinking or significantly reduce their alcohol consumption. Key signs and symptoms of withdrawal include agitation, tremor, nausea and vomiting, sweating and hallucinations. Seizures can occur, usually 24-48 hours after stopping drinking. Delirium tremens describes severe alcohol withdrawal characterised by delirium, haemodynamic instability and autonomic instability. Management strategies involve monitoring for symptoms of alcohol withdrawal using the CIWA scoring tool, giving a reducing course of benzodiazepines (usually chlordiazepoxide) and giving Pabrinex to prevent Wernicke-Korsakoff syndrome.
 

# Definition
 
Alcohol withdrawal is a syndrome that occurs when a patient who is alcohol dependent suddenly stops or drastically reduces their alcohol consumption. There are several stages of alcohol withdrawal that occur over the days following stopping drinking, and severity of withdrawal symptoms ranges from mild symptoms of tremor and insomnia to life-threatening manifestations such as delirium tremens or withdrawal seizures. 
 
# Epidemiology
 
- Alcohol misuse is very common in the UK, with an estimated 24% of adults drinking in a harmful or hazardous way.
- Around 600,000 adults in England are thought to be dependent on alcohol and so at risk of alcohol withdrawal.
- Only 18% of these people with alcohol dependence are receiving treatment.
- In England, there are approximately 1 million alcohol related hospital admissions per year (although alcohol withdrawal represents only a proportion of these)

# Aetiology
 
Chronic alcohol excess causes tolerance to its effects, with reduced GABA and increased glutamate activity in the brain. The patient then relies on alcohol to balance this, and so when they stop drinking the imbalance manifests leading to excess glutamate and over-stimulation of the central nervous system. 

Patients often develop alcohol withdrawal after hospital admission as they are unable to maintain their normal intake whilst an inpatient.

Other cases may occur when a patient decides to go "cold turkey" and stop drinking - patients should be advised to seek help to cut down on their alcohol intake safely.

# Signs and Symptoms
 
From 6 to 12 hours after the last drink, mild withdrawal symptoms may occur:

- Insomnia
- Tremors
- Anxiety
- Agitation
- Nausea and vomiting
- Sweating
- Palpitations

At 12-24 hours, alcohol hallucinosis may begin:

- Visual hallucinations
- Auditory hallucinations
- Tactile disturbances e.g. sensations of crawling bugs on the skin

Alcohol withdrawal seizures are most likely to occur at 24-48 hours - these are usually generalised and tonic-clonic in nature.

At 48-72 hours, delirium tremens may occur:
 
- Delirium and agitation
- Hallucinations and delusions
- Tachycardia
- Hypertension
- Hyperthermia
- Diaphoresis
- Coarse tremor
 
# Differential Diagnosis

- **Benzodiazepine withdrawal**: shares symptoms of insomnia, anxiety, tremor, sweating and nausea, and can also cause seizures; may coexist with alcohol withdrawal and is managed similarly with tapering doses of benzodiazepines. 
- **Sepsis**: can cause delirium and agitation, tachycardia and diaphoresis; hypotension is more common than the hypertension seen in severe alcohol withdrawal and patients may have focal signs of infection.
- **Hepatic encephalopathy**: may occur in patients with decompensated cirrhosis secondary to alcohol, and has similar symptoms of tremor and confusion; ammonia will be elevated and there is often a background of chronic liver disease.
- **Psychosis**: e.g. secondary to schizophrenia may cause similar symptoms of hallucinations, delusions and agitation.
- **Hypoglycaemia**: causes similar symptoms of anxiety, agitation, tremor and diaphoresis; increased risk in patients who drink alcohol.

# Investigations
 
**Bedside tests:**

- **ECG** - arrhythmias and other abnormalities (e.g. QT prolongation) may be seen in severe alcohol withdrawal
- **Capillary blood glucose** for hypoglycaemia 

**Blood tests:**

- **FBC** and **CRP** for inflammatory markers
- **LFTs** for alcoholic liver disease
- **U&Es** for baseline renal function and electrolytes
- **Bone profile** and **magnesium** to monitor electrolytes for refeeding syndrome
- **Blood cultures** if there are signs of infection

**Imaging:**

- **Chest X-ray** if there are signs of aspiration, especially if the patient has had a seizure or has a low GCS
- **CT head** if evidence of head injury or ongoing seizures

# Management
 
- Patients presenting with or at risk of seizures or delirium tremens, or those who are vulnerable, frail or with significant comorbidities should be admitted for medical treatment of alcohol withdrawal
- This involves use of the CIWA (Clinical Institute Withdrawal Assessment of Alcohol) scoring system, which is a standardised way of assessing severity of alcohol withdrawal symptoms in the following domains:
    - Nausea and vomiting
    - Tremor
    - Sweating
    - Anxiety
    - Agitation
    - Tactile disturbances
    - Auditory disturbances
    - Visual disturbances
    - Headache
    - Orientation
- Each domain is scored from 0-7 other than orientation which is 0-4
- A total score of 0-9 represents mild or no withdrawal, 10-19 is moderate withdrawal and > 20 is severe withdrawal
- Higher scores warrant more frequent monitoring of symptoms
- The CIWA score is used to guide prescription of benzodiazepines, which may be given PRN to manage withdrawal symptoms or regularly in a fixed-dose reducing regime over several days (plus PRNs when required)
- Chlordiazepoxide is the first line benzodiazepine used, with oxazepam or lorazepam (shorter-acting benzodiazepines) being used for patients with liver disease
- Alcohol withdrawal seizures should be treated with short acting benzodiazepines (e.g. IV lorazepam) in the first instance
- Delirium tremens is also treated with oral lorazepam, with parenteral lorazepam or haloperidol being second line options
- Pabrinex (1 pair of ampoules once daily) should be given to prevent Wernicke's encephalopathy - if there are signs or symptoms such as ataxia or nystagmus, give treatment dose (two pairs of ampoules TDS)
- Monitor bloods for refeeding syndrome in malnourished patients
- Ensure patients are followed up on discharge and referred to community support services

# NICE Guidelines

[NICE - Alcohol-use disorders: diagnosis and management of physical complications](https://www.nice.org.uk/guidance/cg100/)
 
[NICE CKS - Alcohol Withdrawal](https://cks.nice.org.uk/topics/alcohol-problem-drinking/management/alcohol-misuse/)
 
# References

[BNF - Alcohol Dependence](https://bnf.nice.org.uk/treatment-summaries/alcohol-dependence/) 

[RCEM Learning - Acute Alcohol Withdrawal](https://www.rcemlearning.co.uk/reference/acute-alcohol-withdrawal/)

[Patient UK - Acute alcohol withdrawal and delirium tremens](https://patient.info/doctor/acute-alcohol-withdrawal-and-delirium-tremens)
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Alcohol withdrawal
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Emergency Medicine
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Chlordiazepoxide, a benzodiazepine, manages acute alcohol withdrawal by reducing symptoms such as anxiety, agitation, and seizures through its GABAergic activity, providing a gradual, controlled sedative effect to prevent severe withdrawal complications.
A 58 year old man is brought to A&E by police under section 136. They report he was screaming in the library about seeing and feeling insects crawling all over his skin. His past psychiatric history includes bipolar disorder and alcohol dependence. On inspection, he appears sweaty and confused and a coarse tremor is noted.

Which of the following is the most appropriate treatment?
a