Alcohol and Alcohol Withdrawal Syndromes

April 2014 Regional Training Day 2014, MPH Taunton

Author – Greg Cranston ST4 (of Adventure Medic)

Disclaimer: Summary of key points only. This is intended to supplement your own work on these curriculum items and not provide a complete evidence base on which to change your practice. All drug choices and dosing calculations should be checked with external resources.

Alcohol + Withdrawal Syndromes

(HAP3 – Alcohol and substance abuse)

Interesting_alcoholic_beverages

  • Many people don’t recognise their drinking problem as a health problem, and don’t recognise that other health problems may be attributable to their drinking.
  • We can be the first to help them realise this, and this is probably where we can make the biggest difference to people’s lives with regards to alcohol, because they (hopefully) trust us.
    • Increased risk = weekly units >6/8 (F/M) or alcohol 7/7 days
    • High risk = weekly units >40/50 (F/M)
    • Dependent drinking – must be referred to alcohol liaison team
    • Advise reducing alcohol 10% per week
    • Always consider alcohol in: GI bleed/abdo pain/gastritis/injuries/seizures.
  • Brief interventions have a NNT of 7-9:

o   Simple question of how much (ED)

o   Screening questionnaire e.g. AUDIT (ED or alcohol liaison worker)

o   More detailed alcohol hx + tx options  (Alcohol liaison worker)

    • Do you drink? How often/how much/how long to get through a bottle of x/drink on your own?
    • Dual diagnosis: MH issues, hallucinations, overdose/DSH

 

Beyond the ED (after referral to alcohol liaison)

o   Detox (*Community is more effective than hospital*)

o   Extended brief interventions

o   Treatment groups

o   Route to Residential treatment

  • Only major disease not decreasing since 1970 is liver disease (almost 600% up)

o   Alcohol / Metabolic liver / hepatitis

 

Withdrawal syndromes

o  Guys and St Thomas’ have produced a guideline including the objective scoring systems and overview of management

o   Withdrawal management = preventing brain damage

o   Wernicke’s Encephalopathy vs. intoxication is difficult

o   Chronic/heavy alcoholics are at risk (Vit B not stored properly in malnutrition)

o   The classic triad (ophthalmoplegia/ataxia/confusion) is actually rare (10%)

o   If suspect alcohol misuse + any of [Confusion, reduced GCS, Seizure, memory disturbance, ataxia, hypoglycaemia]

o   2 pairs Pabrinex tds for 2-3 days.  (Short half-life)

o   Pabrinex BEFORE glucose (or can precipitate WE)

o   CIWA-Ar scoring – Benzo usage in withdrawal is now objectively symptom triggered

Life in the fast lane has produced a nice summary on alcohol withdrawal

 

Acute alcoholic hepatitis

o   Jaundiced (stone/Ca/infection) + unwell = possibly needs admission

o   Jaundice + alcohol = usually acute alcoholic hepatitis

o   Nutrition and sepsis management is the key

o   Glasgow alcoholic hepatitis score  >= 9, much lower survival probability

o   Maddrey’s Discriminant Function  (Use  11 secs for PT Control) >= 32, give steroids (But not in ED until sepsis excluded)

o   Complications: SBP, Variceal bleed

o   Decompensated ALD:  There is a 75% 10yr-survival for those who stop drinking.

 

NAFLD (Non-alcoholic fatty liver disease)

o   Associated with the metabolic syndrome

o   Becoming more common reason for transplant

o   Increased ALT is associated with increased risk of diabetes, coronary art disease (OR=1.4), liver disease (OR=4)

 

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