On this page
Referral and warning signs
When to refer
Medically supervised detoxification, usually requiring inpatient admission (HC3/HC4/H), is recommended for patients at risk of moderate-severe withdrawal (history of DTs/seizures, high regular intake, significant comorbidities, older age). URGENT referral needed for established DTs or withdrawal seizures.
Red flags
- Delirium (disorientation, fluctuating consciousness)
- Persistent hallucinations
- Seizures
- Severe autonomic hyperactivity (HR >120, BP >160/100, Temp >38.5°C)
- Signs of Wernicke's encephalopathy (confusion, ataxia, ophthalmoplegia)
Signs and symptoms
- Onset typically 6-24 hours after last drink, peak at 24-48 hours, DTs may occur 48-96 hours.
- Mild Withdrawal (common): Anxiety, agitation, insomnia, tremors ('shakes'), headache, palpitations, sweating (diaphoresis), nausea/vomiting.
- Moderate Withdrawal: Worsening autonomic hyperactivity (tachycardia, hypertension), pronounced tremor, transient hallucinations (visual, tactile, auditory - usually with insight initially).
- Withdrawal Seizures: Generalized tonic-clonic seizures, typically occur 6-48 hours after cessation.
- Delirium Tremens (DTs - Medical Emergency): Severe confusion, disorientation, persistent hallucinations (often visual/frightening), severe agitation, marked autonomic instability (tachycardia >120, hypertension, fever >38.5C, profuse diaphoresis). Usually occurs 48-96 hours after cessation.
Risk factors
- History of heavy, prolonged alcohol consumption (dependence).
- Previous episodes of alcohol withdrawal, especially complicated withdrawal (seizures, DTs).
- Older age.
- Concurrent medical illness (infection, trauma, surgery).
- Significant dehydration or electrolyte imbalance.
Diagnosis
Clinical assessment
Diagnosis based on characteristic symptoms occurring in context of recent cessation/reduction of heavy alcohol use. Use assessment tools (e.g., CIWA-Ar) to quantify severity and guide treatment. Rule out other causes of symptoms (infection, head injury, metabolic disturbance, drug withdrawal).
Investigations
- Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar) score if feasible.
- Blood Glucose.
- Electrolytes (check K+, Mg++, Phosphate).
- Liver Function Tests.
- CBC.
- Consider: Toxicology screen, ECG, CT Head (if seizures new/focal, trauma, or atypical presentation).
Diagnostic criteria
Characteristic withdrawal symptoms (autonomic hyperactivity, tremor, anxiety, +/- seizures, hallucinations, delirium) temporally related to cessation/reduction of heavy alcohol use.
Management
Non-pharmacological management
- Supportive care: Quiet environment, reassurance, frequent orientation.
- Hydration (oral or IV).
- Nutritional support.
- Monitoring: Frequent vital signs, CIWA-Ar score.
Pharmacological treatment
- Benzodiazepines (FIRST LINE): To control agitation, prevent seizures and DTs. Symptom-triggered therapy (based on CIWA-Ar) preferred over fixed schedule if possible. Long-acting agents like Diazepam preferred unless severe liver disease (use Lorazepam).
- - Diazepam: 5-10 mg IV/PO every 1-2 hours based on CIWA score/symptoms. Titrate to light sedation. Very high doses may be needed initially in severe withdrawal.
- Thiamine (Vitamin B1): Give 100 mg IV/IM IMMEDIATELY and BEFORE glucose. Continue daily during withdrawal treatment.
- Multivitamins and Folate.
- Electrolyte Replacement: Correct hypokalemia, hypomagnesemia, hypophosphatemia.
- Phenobarbital: Consider as adjunct or alternative for severe/refractory withdrawal (specialist use, monitor respiration/BP). 100-200mg slow IV.
- Haloperidol: Use cautiously ONLY for severe agitation/hallucinations unresponsive to adequate benzodiazepine doses. 2.5-5mg PO/IM. Monitor for QTc prolongation, EPS. Avoid as monotherapy.
Monitoring
Frequent monitoring of vital signs, withdrawal score (CIWA-Ar), level of sedation, neurological status. Monitor electrolytes, glucose.
Complications
- Seizures, Status epilepticus
- Delirium Tremens
- Aspiration pneumonia
- Arrhythmias
- Rhabdomyolysis
- Wernicke's encephalopathy
- Fluid/electrolyte disturbances
- Trauma from falls/agitation
- Death (esp. from DTs)
Prevention
- Identification of patients at risk.
- Planned, medically supervised detoxification.
- Appropriate use of benzodiazepines during withdrawal.
- Thiamine supplementation.
Patient education
- Explain withdrawal symptoms and the potential dangers (seizures, DTs).
- Explain the role of benzodiazepines and thiamine.
- Emphasize need for completing detoxification process.
- Discuss long-term treatment options for alcohol dependence after detox.
Uganda-specific notes
Severe withdrawal can be life-threatening. Early recognition and treatment with benzodiazepines and thiamine are crucial. CIWA-Ar scoring may not be feasible everywhere; rely on clinical assessment of autonomic hyperactivity and mental status. Access to inpatient detox is limited.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 1, Section 1.3.12.2 (Management section)
- Uganda Clinical Guidelines (UCG) 2023
Chapter 9, Section 9.2.5 (Refers back to Chapter 1 for withdrawal)