Generally we DON’T admit patients acutely solely for “Detox”

However the following groups should be admitted [taken from trust guide]

• Patients requiring admission for another reason – refer to appropriate specialty (e.g.  Head injury going to CDU, or Upper GI bleed going to medicine)
• ALL patients with symptoms / signs of Wernicke’s – medicine
• ALL patients with Delirium Tremens – medicine
• ALL alcohol withdrawal fits if patient to remain abstinent – medicine
• ALL alcohol related seizures with possible other trigger – medicnie
• ALL decompensated alcoholic liver disease – medicine

If admitted to CDU – complete the PAT tool

Chlordiazepoxide

In ED USE the Chlordiazepoxide PowerPlan so appropriate reducing regime prescribed

Prescribing single doses has directly lead to harms (due to delayed treatment)

 

The following is a guide (the power plan does it for you) and the dose should be regularly reviewed – (CIWA-Ar is recommended to aid reviews)

Discharge: patients should not be sent home with >3 doses of chlordiazepoxide [unless agreed with community services]

 

Wernicke’s Encephalopathy

Wernicke’s has a mortality of 10-20%, so should be looked for, and treated appropriately

Signs/Symps

• Acute peripheral neuritis
• Alcohol withdrawal fits
• Ataxia – not due to intoxication
• Confusion/Coma/Reduced Consciousness – not due to intoxication
• Delirium Tremens
• Hypotension
• Hypothermia
• Memory disturbance
• Ophthalmoplegia – paralysis of the extra-ocular muscles controlling eye movements
• Physically unwell

Managment

• Treatment (under medicine) – Thiamine or Pabrinex 2 pairs
• Prophylaxis – Thiamine or Pabrinex 1 pair.
• Decompensated Liver Disease – Add Lactulose 15ml BD (aim 2-3 stool/day)

Delerium Tremens (DT’s)

This the most severe end of the withdrawal spectrum, and tends to come on suddenly 48-72 hours after stopping (or significant reduction) of alcohol consumption. It is typified by autonomic hyperactivity (Mortality is 15-35%).

Signs/Symps

• Agitation
• Confusion (Profound)
• Hallucinations(visual/auditory/tactile)
• Fever
• Tachycardia
• Hypertension
• Heavy sweating

Managment

• Admission – Medicine, will need close monitoring
• Chlordiazepoxide – Reducing regime & PRN
• Thiamine/Pabrinex – 2 pairs, TDS
• Seizures – Standard therapy with early benzodiazepines

Arranging Follow Up

AUDIT SCORE RISK CATEGORY DESIRED ACTION – Calculator
0 –7 Lower risk – No intervention required
8 –15 Increasing risk – Brief Advice/offer Brief Intervention
16-19 Higher risk – Extended BA/Intervention
20+ Possible dependence – Referral to services

Those requiring follow up – copy of the assessment and patient details can be left in the drug&alcohol box in majors area, for the alcohol liaison team