Psychiatric disorders associated with alcohol misuse
There are two potentially life-threatening alcohol-related conditions which are dealt with in casualty departments and general medical and surgical wards, as well as in psychiatric hospitals.They are alcohol withdrawal syndrome with seizures (delirium tremens) and Wernicke’s encephalopathy.
When a person who has been drinking over half a bottle of spirits a day, or equivalent, such as six to seven pints of cider, premier beer or premier lager (that is, over 15 “units”) per day, suddenly stops drinking, it typically results in anxiety, tremor and insomnia. Figure 1 shows the analogy that can be drawn with a spring. However, sometimes the response is more severe, and agitation, confusion and even hallucinations ensue, which put the person and sometimes other patients or staff in danger. This can be prevented by anticipating that a withdrawal syndrome might develop, from the patient’s or the family’s report of heavy drinking, from other evidence of regular recent alcohol consumption such as alcohol in the breath, unexplained raised mean red cell volume (MCV) or gamma glutamyl transferase (GGT), or by identifying early withdrawal symptoms (tachycardia, anxiety, sweating or tremor).
Early initiation of a sufficient dose of oral benzodiazepine1 (for example, diazepam 40mg stat followed by 20 mg four to six hourly for 24 hours and then reduced to zero over four days) will usually prevent the full-blown withdrawal syndrome.
Protocols should be available so that nurses can monitor symptoms and use extra medication as required. Giving excess benzodiazepine will result in an unsteady or sleepy patient, whereas not giving a sufficient dose has been associated with a patient suffering a withdrawal seizure or frightening incidents such as an assault on a nurse or a leap from a window to escape from imagined persecutors. If delusions and hallucinations emerge, an antipsychotic medication such as haloperidol should be used.
Intravenous (IV) diazepam (10 to 20 mg) is required if the patient has already reached the point of confusion. IV or intramuscular (IM) droperidol (10 mg) is added if agitation is severe. Restraint may be necessary.
Withdrawal medication Chlormethiazole and benzodiazepines have been used.
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Citation: Hospital Pharmacist URI: 10974031