PSYCHOPHARMACOLOGIC MANAGEMENT OF THE PATIENT IN ACUTE ALCOHOL WITHDRAWAL
One of the more difficult aspects of managing alcohol withdrawal is that the withdrawal syndrome often surprises care givers. Some patients who experience alcohol withdrawal in a hospital setting are themselves surprised at this turn of events due to ignorance denial or other cognitive impairment. Often the admitting physician is unaware of the patient’s alcohol history or has colluded with the patient in the denial process. Patients, families and physicians all are known to minimize alcohol usage.
These are formidable obstacles to overcome and very careful nursing assessment is critical if we are to minimize events of unexpected alcohol withdrawal, Whenever evidence exists to suggest recent alcohol ingestion these clues should be validated if possible and communicated to the healthcare team.
Six to eight hours after drinking is typically when the first signs of alcohol withdrawal are experienced. Earliest withdrawal symptoms are subjective and may present as complaints of nervousness or anxiety. Shortly after this, there may be a mild but noticeable increase in autonomic nervous system activity. Blood pressure and heart rate may begin to increase. Other signs include restlessness, inattentiveness, irritability, increased startle response and onset of a fine postural tremor. Ideally, this is the point at which intervention with benzodiazepines would begin.
At about 24 hours after the last drink, symptoms of alcohol withdrawal become more pronounced. Transient confusion and inappropriate verbal responses may be noted. Nausea and vomiting may occur. Disturbed sleep often including nightmares is typical. If benzodiazepines have not been offered earlier, now is the time to begin frequent dosage based on subjective and objective data.
Withdrawal seizures are not uncommon between 8 and 48 hours after the last drink. Patients may experience u to several grand mal type seizures in a short period of time within this window (8 – 48 hours). Alcohol withdrawal seizures are not usually focal seizures, therefore, are not typically treated with anti-convulsants.
The benzodiazepines are the drug of choice to provide a safe alcohol withdrawal. Their rapid onset permits quick intervention and they can be given in high doses when needed to prevent delirium tremens. I/V administration of Valium is appropriate for seizure control, as well. It is not unusual to use Valium 10-20 mg or more every hour in the early hours of acute alcohol withdrawal. Once benzodiazepines are used significantly during withdrawal as adequate detoxification through daily dosage, reduction must be instituted to prevent further withdrawal from the benzodiazepine. In hospitals where an alcohol and drug recovery unit exists, calls to the medical director and nursing staff for consultation in the management of acute alcohol withdrawal is highly recommended.
While Valium is widely used for alcohol withdrawal, other benzodiazepines may be substituted. The half-life of the drug should be considered in choosing a drug to treat alcohol withdrawal in addition to onset of action. Benzodiazepines with a lengthy half-life provide a more stable blood level and less severe withdrawal problems.