.

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(Alcohol Related Disorder)
3

1. (Alcohol Use Disorder)

2. (Alcohol Induced
Disorder)

3. (Alcohol Related Physical Illness)

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(Alcohol Related Physical Illness)



(ALCOHOL
WITHDRAWAL: PATHOPHYSIOLOGY, DIAGNOSIS AND TREATMENT)

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THE EFFECTS OF ALCOHOL ON THE BRAIN

Significant shrinking of the brain

50% - 75% show cognitive impairment
Effects remain even after detoxification &
abstinence
Alcohol dementia is 2nd-leading cause of
adult dementia

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Alcohol and the GABA Receptor

When alcohol enters the brain, it binds to
GABA receptors and amplifies the
hyperpolarization effect of GABA.
The neuron activity is further diminished
This accounts for some
of the sedative affects
of alcohol

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Drugs That Influence Neurotransmitters

Change in Neurotransmission

Effect on Neurotransmitter
release or availability

Drug that acts this way

increase the number of impulses

increased neurotransmitter release

nicotine, alcohol, opiates

release neurotransmitter from

vesicles with or without impulses

increased neurotransmitter release

amphetamines
methamphetamines

release more neurotransmitter in

response to an impulse

increased neurotransmitter release

nicotine

block reuptake

more neurotransmitter present in

synaptic cleft

cocaine
amphetamine

produce less neurotransmitter

less neurotransmitter in synaptic

cleft

probably does not work this way

prevent vesicles from releasing

neurotransmitter

less neurotransmitter released

No drug example

block receptor with another

molecule

no change in the amount of

neurotransmitter released, or
neurotransmitter cannot bind to its
receptor on postsynaptic neuron

LSD
caffeine


Alcohol: Effects on the Body and Behavior

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Overview:

Definitions
Statistics on teen drinking
Short- and long-term effects of
alcohol
Blood alcohol levels
Introduction to fetal alcohol syndrome
(FAS)

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Short-term Effects(5,6)
Slower reaction times/reflexes
Heavy sweating
Blurry vision
Nausea and vomiting
Lowered reasoning ability

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Short-term Effects (cont.)(5,6)

Poor motor coordination

Slower heart rate/breathing rate
Increased blood pressure
Anxiety/restlessness
Lower inhibition

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Short-term Effects (cont.)(5,6)

Mental confusion
Memory loss
Coma
Death from respiratory arrest

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Long-term Effects(5,6)
Nervous system
Muscles
Lungs
Liver

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Long-term Effects (cont.)(5,6)

Sexual organs
Brain
Heart
Esophagus/stomach

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Blood Alcohol Level: Whats It All About?(6)

Blood alcohol level (BAL) depends on:

Weight
Amount of food and water in
stomach
Carbonated alcoholic beverages
Gender

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Blood Alcohol Levels: So What?(8)

BAL = 0.03 to 0.12 (Euphoria)

Self-confident/daring
Short attention span
Poor judgment
Fine motor skills impaired

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Blood Alcohol Levels(8)

BAL = 0.09 to 0.25 (Excitement)

Sleepy
Memory loss
Reaction time decreased
Uncoordinated/loss of balance
Blurry vision and impaired senses

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Blood Alcohol Levels(8)

BAL = 0.18 to 0.30 (Confusion)

Confused/dizzy
Highly emotional
Cannot see/slurred speech
Uncoordinated/sleepy
May not feel pain as easily

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Blood Alcohol Levels(8)

BAL = 0.25 to 0.40 (Stupor)

Can barely move at all

Cannot respond to stimuli
Cannot stand or walk
Vomiting
Lapse in and out of consciousness

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Blood Alcohol Levels(8)

BAL = 0.35 to 0.50 (Coma)

Unconscious
Reflexes depressed
Decreased body temperature
Decreased breathing rate
Decreased heart rate
Could die

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Blood Alcohol Levels(8)

BAL = Greater than 0.50 (Death)

Breathing stops
That says it all!

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Driving Limits(6)
Most states set the legal level of
intoxication at 0.08 to 0.10

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Drinking is a Personal Choice but Who

Else is Affected?

Friends and family

Strangers
Unborn babies
Fetal alcohol syndrome

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benzodiazepine
(Guideline for alcohol withdrawal management)

Patterns of Alcohol Use

Alcohol
Problems

At Risk

Mild

Moderate

Severe

Low Risk

NIAAA 2003


At Risk or Drinking Problem

Alcohol Education, Brief Intervention:
Brief Advice, Brief Counseling

WHO 2001


Alcohol Dependence

WHO 2001

setting




-



withdrawal


DTs

chronic liver disease,



malnutrition,electrolyte imbalance

John Saunders 2003












, DTs

John Saunders 2003

DTs

John Saunders 2003



1.

2.

3.



4.
5.
6.
7.
8.

Early recognition and correct management of

the initial milder stages of withdrawal is
crucial in prevention of its progression into
severe and life-threatening stages

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John Saunders 2003

 ALCOHOL WITHDRAWAL


withdrawal

withdrawal


withdrawal

John Saunders 2003

 ALCOHOL WITHDRAWAL


withdrawal
1.

2.
3.

4.

withdrawal

withdrawal, DTs,

chronic liver disease

John Saunders 2003

1.

2.

3.

4.

5.

 ALCOHOL WITHDRAWAL

Alcohol withdrawal scale

(AWS) ,Clinical Institute Withdrawal Scale for
Alcohol - Revised Version (CIWA-R) Minneapolis
Detoxification Scale (MINDS)

baseline

John Saunders 2003


Mild symptoms
AWS 1-4, CIWA-R 1-9,MINDS 1-9

Moderate symptoms
AWS 5-14, CIWA-R 10-18, MINDS 10-20

Severe symptoms
AWS 15, CIWA-R 19, MINDS > 20

John Saunders 2003

DTs

John Saunders 2003






4S
1) Sedation
2) Symptomatic Relief
3) Supplement
4) Supportive environment
Recognition and management of complication

ALCOHOL DETOXIFICATION
1. SEDATION :
Protocol 1 : Fixed (regular) schedule regimen
Protocol 2 : Symptom-triggered (front-loading)
regimen
Protocol 3 : Loading dose diazepam regimen
Protocol 4 : Intravenous diazepam

2. SYMTOMATIC RELIEF
3. SUPPLEMENT
4. SUPPORTIVE ENVIRONMENT

ALCOHOL DETOXIFICATION
Sedation:

Benzodiazepines

long half-life:
Diazepam 5-20 mg , oral q 4-6 hrs
Chlordiazepoxide 25-100 mg, oral 4-6 hrs
short half-life:
imparied liver function
Lorazepam 2-10 mg, oral 4-6 hrs

Benzodiazepine

SEDATION
Protocol 1 : Fixed (regular) schedule regimen

AWS >5

SEDATION
Protocol 1 : Fixed (regular) schedule regimen
(general
ward)

:
6

SEDATION
Protocol 1 : Fixed (regular) schedule regimen
6 am

12 md

6 pm

12 mn

Day1

10mg

10mg

10mg

10mg

Day 2

10mg

10mg

10mg

10mg

Day 3

5mg

5mg

5mg

10mg

Day 4

5mg

5mg

5mg

10mg

Day 5

Nil

5mg

Nil

5mg

DZP

SEDATION
Protocol 2 : Symptom-triggered regimen

monitor
benzodiazepine

SEDATION
Protocol 2 : Symptom-triggered regimen

Clinical Institute Withdrawal Assessment Alcohol
(CIWAAr)
Alcohol Withdrawal Scale (AWS)
Minneapolis Detoxification Scale (MINDS)

Nurse staff

withdrawal

SEDATION
Protocol 2 : Symptom-triggered regimen


2-5
benzodiazepine

4
25 2-3

SEDATION
Protocol 2 : Symptom-triggered regimen
AWS
SCORE

CIWA-Ar
SCORE

MINDS
SCORE

DIAZEPAM DOSE

Nil

1-4

1-9

1-9

Nil

5-9

10-14

10-14

l5-10 mg

10-14

15-18

15-20

10 mg switch to
protocol 3

15

19

> 20

Loading dose regimen

Lorazepam Lorazepam 1 mg Diazepam 5 mg

SEDATION
Protocol 3 : Loading dose diazepam regimen

benzodiazepine





(
)

24

SEDATION
Protocol 3 : Loading dose diazepam regimen

DZP 20mg orally 2 . (

)
2-4 . monitor withdrawal
symptoms
DZP
(additional dose) 2-4 .

loading regime
4 .

SEDATION
Protocol 3 : Loading dose diazepam regimen

DZP > 120mg 12 .

DZP

4
25% 3
10
withdrawal,
,

SEDATION
Protocol 4 : Intravenous diazepam

:Alcohol Withdrawal Delirium (Delirium Tremens)

DZP 10 mg IV slowly
3 30 ( )
DZP 10 mg IV 2 .

ALCOHOL DETOXIFICATION
Supplements:


thiamine, magnesium,

phosphate, folate, zinc, vitamins A, D, E, C
B
thiamine (vitamin B1)
WernickeKosarkoff Syndrome
Nutrition and Hydration

ALCOHOL DETOXIFICATION
Supplements:

Thiamine
Thiamine: B1 100mg IM daily x 3 days
B1 100 mg oral 3 times a day
Remark: thiamine dextrose

MTV oral 3 times a day

Potassium, Magnesium, Phosphate, Folate

ALCOHOL DETOXIFICATION
Supportive Environment:

supportive counseling and reassurances



(sleep hygiene)

ALCOHOL DETOXIFICATION
Symptomatic Relief:




Metoclopramide , Antacid

Paracetamol ,Kaoline

-Adrenergic receptor antagonists
Propanolol 10 40 mg 6
Atenolol 50 100 mg/day
2 Adrenergic agonists

clonidine
Carbarmazepine

600 800 mg 48
200 mg
Antipsychotic drugs

Antipsychotic drugs

severe




hallucination Antipsychotic drugs

haloperidol 2.5-5mg IM
6 . (as required)
2.5-5mg 6 .

(48)

GUIDELINE FOR ALCOHOL WITHDRAWAL

MANAGEMENT
Withdrawal
Assessment

AWS >15;CIWA>19; MINDS>20

AWS q -1 hr

Lorazepam (2mg) 2-4 tab

DZP(5mg) 4-8 tab oral
Valium 10 mg IV

Repeat 3 doses

AWS 10-14 ;CIWA 15-18;

MINDS 15-20

AWS 5-9;CIWA 10-14;

MINDS 10-14

AWS < 5;CIWA <10;

MINDS < 10

AWS q 2 hrs

AWS q 4 hrs

AWS q 8 hrs
Day 0-5

Lorazepam (2mg) 1-2 tab

DZP(5mg) 2-4 tab oral
Valium 10 mg IV

Lorazepam (2mg) 0.5-1 tab

DZP(5mg) 1-2 tab oral

Observe

Note: CBC

AWS q 24 hr Day 5-7

DZP 40 mg LFT

Notify doctor

AWS < 5; CIWA<10; MINDS<10 5 admit 3

AWS, CIWA-Ar MINDS

Withdrawal scales

(diagnostic instrument)

withdrawal


John Saunders 2003

 2


30

1
1.




2
2.

3.

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