2. Alcohol withdrawal
(NICE Pathways 2015)
• Someone who has been drinking alcohol heavily for a considerable
period of time (i.e. several days), or has been drinking heavily and
then ‘topped up’ over a period of time without respite, is in danger of
alcohol withdrawal syndrome when their blood alcohol returns to
minimum level.
• Alcohol withdrawal syndrome is a life-threatening condition.
• Immediate care is required for someone who is likely to experience
seizures or delirium tremens.
• Anyone at high or medium risk should be assessed in A&E.
• High risk individuals and those under 16 years should be
admitted to hospital.
3. Alcohol withdrawal symptoms
(Guys & St. Thomas’ NHS Foundation Trust (2012)
Symptoms and signs of alcohol withdrawal syndrome can be:
Anxiety
Agitation
Irritability
Nausea
Vomiting
Diarrhoea
Convulsions
Insomnia
Absence of any of these does not exclude withdrawal symptoms.
Tremor of hands, tongue,
eyelids
Hallucinations
Sweating fever with or
without infection
Delirium
Tachycardia
Hypertension
4. Alcohol withdrawal syndrome
(Guys & St. Thomas NHS Foundation Trust (2012)
• Symptoms will present within 6 – 8 hours of the last drink.
• These include epileptiform seizures within 12 to 48 hours
of alcohol cessation.
• Fits are rare beyond 48 hours following alcohol cessation.
• People with known alcohol dependency should also be
given prophylactic vitamin B supplement (Pabrinex).
Alcohol related seizures
5. • Delirium tremens (DTs) occurs in about 5% of patients undergoing
alcohol withdrawal.
• Untreated, DTs is fatal in 15-20% of patients whilst early detection
and prompt initiation of treatment usually prevents onset.
• Onset of DTs is 2-5 days (most commonly at 2-3 days) following
cessation and represents a medical emergency.
• If untreated, death may result from respiratory and cardiovascular
collapse or cardiac arrhythmias.
• Patients most at risk are those with a high fever (>104°F/39.9°C),
tachycardia, dehydration and an associated illness (e.g. pneumonia
or pancreatitis), general debility or where the diagnosis is delayed.
Delirium tremens (DTs)
Alcohol withdrawal syndrome
(Guys & St. Thomas NHS Foundation Trust (2012)
6. Delirium tremens (DTs) symptoms
• Severe tremor
• Clouding of consciousness
• Delusions
• Confusion and disorientation
• Tachycardia
• Agitation or violent behaviour
• Delirium
• Fever, with or without infection: temperature > 101°F/38.3°C
• Severe hallucinations, often evoke extreme fear (mainly visual, may
be tactile or auditory)
Alcohol withdrawal syndrome (cont.)
(Guys & St. Thomas NHS Foundation Trust (2012)
7. Immediate management of alcohol
withdrawal syndrome (NICE Pathways 2015)
• Alcohol withdrawal syndrome is commonly managed in
hospital through a reducing dose of benzodiazepines
(diazepam or chlordiazepoxide). Clormethiazole may be
prescribed for admitted inpatients.
• Delirium tremens should be treated firstly with a quick-acting
benzodiazepine (lorazepam) and psychotic symptoms should
be managed with haloperidol or olanzapine.
• Symptoms should be observed and recorded to determine the
effectiveness of the treatment.
8. References
• Guys and St Thomas NHS Foundation Trust (2012) Clinical Guideline. DTC
Reference 10052a. Available at: http://www.guysandstthomas.nhs.uk/resources/our-
services/acute-medicine-gi-surgery/elderly-care/alcohol-withdrawal-syndrome.pdf
• NICE Pathways (2015) Acute alcohol withdrawal. Accessed 28.7.15. Available at:
http://pathways.nice.org.uk/pathways/alcohol-use-disorders/acute-alcohol-withdrawal