Managing Alcohol Withdrawal Syndrome
Mercy Hospital & Trauma Center
Janesville, WI
Jenny Kleinert, BSW, BSN, RN-BC, PMHN
jkleinert@mhsjvl.org
Mercy Options:
Inpatient Behavioral Health Unit – Psychiatry and Detox
608-756-6508
Frequently Used Terms
Term
Characteristics
Alcohol abuse
Alcohol dependence
Alcohol withdrawal syndrome
(AWS)
Delirium tremens (DTs)
Regular excessive use of alcohol
with failure to meet
responsibilities, such as work and
family roles; Often drink during
dangerous situations, such as
driving or operating machinery;
Legal problems occur secondary
to alcohol use; Continue to drink
in spite of effect on relationships;
Need to drink more alcohol to
achieve the same pleasurable
effect
Crave alcohol; Lose the ability to
limit drinking; AWS occurs when
abstinence occurs abruptly;
Develop a tolerance for alcohol;
Consume more alcohol than even
intended when the individual
began drinking; Numerous
attempts to cut down or stop
drinking; Always
finding/drinking/recovering from
alcohol; Give up/reduce
activities because of drinking
habits; Continue to indulge in
alcohol in spite of being informed
of the dangers to health and
relationships
Criterion A: Cessation or
reduction of alcohol use that has
been heavy and prolonged
Criterion B: Two or more clinical
manifestations that occur within
hours or days of the last drink;
Other medical or mental health
problems are not the cause of the
patient's manifestations
The worst and severest form of
AWS begins 48-96 hours after
last drink, peaks at Day 5;
Autonomic hyperactivity:
tachycardia, tachypnea,
hypertension, tremors,
hyperthermia; Reduce clarity of
surroundings; Memory deficit,
disorientation, language
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disturbance, and hallucinations;
Perceptual disruption;
Disturbances develop in a short
period of time and fluctuate
during the day
A form of alcoholic psychosis
characterized primarily by
auditory hallucinations occurring
in a clear sensorium, abject fear,
Alcohol hallucinosis
and delusions of persecution.
The condition develops shortly
after prolonged and heavy alcohol
intake is stopped or reduced,
usually within 48 hours.
Usually a single seizure; Can
occur in the absence of AWS or
DTs; Generalized tonic-clonic
Alcohol withdrawal seizures
convulsions; Primarily occurs in
patients with chronic alcoholism;
If left untreated, may progress to
DTs
Due to thiamine deficiency; An
acute life-threatening neurological
Wernicke's syndrome
disordered; Exhibited by
paralysis of the eye muscle,
nystagmus, and ataxi
Due to thiamine deficiency;
Manifested by inability to recall
information, inability to assimilate
Korsakoff's psychosis
new information, decreased
spontaneity, decreased initiative,
and confabulation
NOTE: Nurse's need to understand these terms in order to be
proactive in managing the care of a patient who has a problem
with alcohol.
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The CAGE Questionnaire
More than two positive responses to the questions suggest alcohol
dependence and indicate further assessment is warranted.
1.
2.
3.
4.
Have you ever felt you ought to Cut down on your drinking?
Have people Annoyed you by criticizing your drinking?
Have you ever felt Guilty about your drinking?
Have you ever had a drink first thing in the morning to steady
your nerves or to get rid of a hangover (Eye-opener)?
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Symptoms of Alcohol Withdrawal
Syndrome
Time of
occurrence after
last alcohol use
Symptoms
6 to 12 hours
Minor withdrawal
symptoms: insomnia,
tremulousness, mild
anxiety,
gastrointestinal upset,
headache, diaphoresis,
palpitations, anorexia
12 to 24 hours
(symptoms
usually resolve
within 48 hours)
24 to 48 hours
(symptoms
reported as early
as two hours after
cessation)
48 to 72 hours
(symptoms peak
at five days)
Alcohlic hallucinosis:
visual, auditory, or
tactile hallucinations
Withdrawal seizures:
generalizaed tonicclonic seizures
Alcohol withdrawal
delirium (delirium
tremens):
hallucinations
(predominately visual),
disorientation,
tachycardia,
hypertension, lowgrade fever, agitation,
diaphoresis
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Effects of alcohol on the body and supportive care for patients with alcohol
withdrawal syndrome
System affected/
cancer risk
Effect
Mechanism
Central nervous
system
Impaired judgement and
memory
Imparied balance and
motor coordination
Sleep disturbances
Peripheral neuropathy
Alcohol-related
psychiatric disroders
Dementia
Depression
Hallucinations
Wenicke encephalopathy
Korsakoff syndrom
Cardiovascular
Beneficial effects:
Possible reduction in risk
for death d/t
cardiovascular conditions
(1-2 drinks per day over
long periods)
Deleterious effects:
Decreased myocardial
contractility
Cardiomyopathy
Dysrhythmias
Mild to moderate
hypertension
Hematopoietic
Increased size of RBCs
(mean corpuscular
volume)
Decreased production of
WBCs
Thrombocytopenia
Nursing Interventions
Maintain patient's safety
Provide quiet
Effects are due to the
environment
combination of the direct Have patient avoid
toxic effects of alcohol on television and other
neural tissue, thiamine
activities that may
definciency, and
contribute to
nutritional deficits
hallucinations
Initiate interventions to
prevent falls
Beneficial effects occur
because alcohol
increases levels of highdensity lipoprotein and
decreases platelet
aggregation
Deleterious effects are
due to the direct toxic
effects of alcohol on
cardiac muscle and the
vasopressor effects of
ethanol
Monitoring patients for
dysrhythmias
Provide rest to reduce
fatigue
Monitor for hypertension
Effects are due to the
direct toxic effects of
alcohol on bone marrow
that cause suppression
and malnutrition-related
folate deficiency
Monitor blood values and
bleeding
Do a complete nutritional
assessment
Encourage patient to eat
nutritiously
Maintain a safe
environment and initiate
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interventions to avoid
injury
Prevent infection
Gastrointestinal
Esophageal inflammation
Mallory-Weiss lesions
Esohphageal varices
Acute pancreatitis
Alcohol-induced hepatitis
Cirrhosis
Musculoskeletal
Cancer risk
Effects occur because
alcohol stimulates an
increase in acid
production and causes
direct damage of the
gastric mucosal barrier;
cirrhosis occurs as a
result of fatty buildup in
the liver
Monitor patient for
gastroentestinal bleeding
Monitor for alterations in
liver function
Maintain a safe
Effects on muscle tissue environment
are due to the direct toxic
effects of alcohol on
Initiate interventions to
muscle tissue. Skeletal
prevent falls
effects are due to the
direct toxic effects of
alcohol on osteoblasts
Alcohol myopathy
Lower bone density
Increased risk for
fractures
Increased risk for caner
of the
Breast
Esophagus
Oral cavity
Overall risk of cancer is
10 times greater in
persons who are
alcoholic than in the
general popluation
Alcohol is not a directacting carcinogen but
one of its metabolites,
acetaldehyde, may act
as a tumor promoter.
Chronic alcohol use also
causes increased
degradation or retinol by
the liver and results in
vitamin A deficiency,
which is associated with
an increased incidence
of cancer
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Explain effects of chronic
alcohol use
Offer information on
treatment options and
sources of support
Medications Frequently Used for AWS
Benzodiazepines
 Examples:
o lorazepam (Ativan),
 Only benzodiazepine recommended for IM administration (d/t erratic
absorption of other agents administered the same route)
o chlordiazepoxide (Librium),
o valium (Diazepam)
 Recommended over other medications because they have better documented efficacy, are
safer, and are less likely to lead to abuse
o The potential for abuse is higher with benzodiazepines with a rapid onset of action,
than it is for those with a slower onset of action
 Reduces the severity of alcohol withdrawal, including the incidence of delirium and seizures
 Dosage should be individualized, based on severity of withdrawal (as indicated by the
withdrawal scale score, or CIWA-Ar)
NOTE: Other medications may be used to treat alcohol withdrawal but are not recommended
as monotherapy, they should be used in combination with benzodiazepines.
Vitamins



Example: thiamine (Vitamin B)
o Essential nutrient to all tissues of the body for carbohydrate metabolism
o Suggested dosing: 50-100mg PO qday X 3-7days (or until treatment of alcohol
withdrawal ends)
Corrects deficiencies
Prevents Wernicke-Korsakoff syndrome
Alpha-adrenergic agonists
 Example: clonidine (Catapres)
 Studies show that this may help alleviate symptoms in patients with mild to moderate
alcohol withdrawal
o Effect on rate of delirium and seizures is unknown
Anticonvulsants
 Examples: valproic acid (Depakote), cabamazepine (Tegretol), gabapentin (Neurontin)
 Research supports use to prevent seizures related to alcohol withdrawal
Beta-blockers
 Examples: atenolol (Tenormin), propranolol (Inderal)
 Adjunctive therapy
o May be useful for patient’s with co-morbid conditions (i.e. – coronary artery disease)
Neuroleptics
 Examples: chlorpromazine (Thorazine) or haloperidol (Haldol)
 May reduce symptoms related to alcohol withdrawal, but are significantly less effective than
benzodiazepines
 May be indicated for severe agitation, thought disorders, or hallucinations
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
NOTE: when used alone, risk for seizure increases and delirium is unchanged
Ethyl alcohol
***Not recommended. There is little evidence to support its use OR prove that it is safer and/or
more effective than the use of benzodiazepines.
Miscellaneous
(NOTE: The following medications should only be initiated once withdrawal is resolved and
the patient intends on abstaining from continued alcohol use.)

disulfiram (Antabuse)
o Used to deter relapse
o Produces adverse symptoms (when mixed with alcohol)
 Violent throbbing headache
 Nausea and vomiting
 Chest pain
 Palpitations
 Breathlessness
 Flushed face
 Tachycardia
 Arrhythmias
 Decrease BP leading to vertigo, blurred vision, and possible collapse
o Reaction can occur within 10 minutes of consuming alcohol
o Very small amounts can induce reaction (medications – cough mixtures, mouthwashes,
foods)
o Only useful for those individuals intending on abstaining from alcohol indefinitely

acamprosate (Campral)
o Reduces craving for alcohol
o Therapy recommended for 6-12 months

naltrexone (Depade)
o Opioid antagonist
 Blocks the effects of the body’s natural opioid-like substances (endorphins)
 Inhibits the pleasant feelings associated with alcohol use  overtime it breaks
the association between pleasure and alcohol in the brain
 ***NOTE: This medication will block ALL other opioid analgesics!!!
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Benzodiazepines Most Commonly
Used for the Effective
Management of Alcohol
Withdrawal
Ativan
Route
P.O.
I.V.
I.M.
(lorazepam)
Onset
Peak
1 hr
2 hr
60-90
5 min
min
60-90
15-30 min
min
(chlordiazepodie
Librium hydrochloride)
Route
Onset
Peak
P.O.
Unknown
1/2-4 hr
Valium
Route
P.O.
(diazepam)
Onset
Peak
30 min
2 hr
I.V.
I.M.
P.R.
1-5 min
Unknown
Unknown
1-5 min
2 hr
90 min
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Duration
12-24 hr
6-8 hr
6-8 hr
Duration
Unknown
Duration
20-80 hr
15-60
min
Unknown
Unknown
References
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th
ed., text rev.). Washington, D.C.
Burton, J. (2010). Alcohol withdrawal syndrome. MedSurg Matters!, 19(5), 7-12.
Compton, P. (2002). Caring for an alcohol-dependent. Nursing2002, 32(12), 58-63.
Doyle, L., Keogh, B., & Lynch, A. (2010). Pharmacological management of alcohol dependence
syndrome. Mental Health Practice, 14(1), 14-19.
Kelly, A., & Saucier, J. (2004). Is your patient suffering from alcohol withdrawal?. RN, 67(2), 27-32.
Keys, V. (2011). Alcohol withdrawal during hospitalization. The American Journal of Nursing, 111(1).
40-44.
McKinley, M. (2005). Alcohol withdrawal syndrome: Overlooked and mismanaged?. Critical Care
Nurse, 25(3), 40-49.
Molnar, A. (2006). One drink over the line. Nursing2006 Critical Care, 1(6), 20-33.
Videbeck, S. (2008). Psychiatric-mental health nursing, 4th Ed. Philadelphia, PA: Lippincott Williams
& Wilkins.
Vincent, W., Smith, K., Winstead, S., & Lewis, D. (2007). Review of alcohol withdrawal in the
hospitalized patient: Diagnosis and assessment. Orthopedics, 30(5), 358-361.
Vincent, W., Smith, K., Winstead, S., & Lewis, D. (2007). Review of alcohol withdrawal in the
hospitalized patient: Management. Orthopedics, 30(6), 446-449.
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