Thursday, 24 October 2013

Alcohol Assessment

Alcohol and substance abuse has its own separate curricular component in HST. Core training integrated alcohol into most of the individual components.

E-learning for health hospital pathway 

BMJ Learning
Alcohol Liver Disease 
Alcohol Withdrawal in the ED

Alcohol in Older Adults
Ethylene Glycol
Royal College of Psychiatrists
RCPsych Leaflets

The Scale of the Problem
- 33.5% of adults aged 16 and over have a disorder of alcohol use
- 39% of men and 28% of women
- 21% of men and 15% of women (18% overall) are thought to be binge drinkers

In York:
- 18% of all ambulance journeys were due to alcohol
- 9.8% of attendances were alcohol-related (553 patients)
- Between 21:00 and 09:00, this rose to 19.7%
- Alcohol was involved in 45% of mental health attendances
- The alcohol group was heavily over-represented in the patients removed by police (100%), refusing treatment (55%) and leaving prior to their treatment (41%)
- 10.3% of alcohol-related attendees remained in the ED for >4hours compared with 5.9% of non-alcohol-related attendees

In Northern Ireland:      
- Alcohol misuse was a factor in 60% of patient suicides
- Become more common over the past 10 years.
- Alcohol a factor in 70% of suicides of young people known to mental health services.
- Alcohol dependence was also the most common clinical diagnosis in patients convicted of homicide, with more than half known to have a problem prior to conviction.
- In homicide and suicide generally, alcohol misuse was a more common feature in Northern Ireland than in the other UK countries

Simple withdrawal
This has a short duration of one to four days and is associated with nausea, tremors, anxiety, sweating, and seizures.

Complex withdrawal
This can sometimes last up to nine or 10 days. Symptoms and signs of complex withdrawal are more severe. It is associated with confusion, hallucinations, paranoia, and delirium tremens.

- 50% of seizures occur on admission and 90% occur within nine hours of admission to hospital
- Seizures that relate to alcohol withdrawal are usually generalised and take place 12 to 48 hours after stopping alcohol
- Seizures occurring more than 48 hours after stopping alcohol are rare

- 50% of hallucinations occur within 21 hours and 90% occur within 64 hours of admission to hospital
- Alcoholic hallucinations can occur in the absence of delirium tremens.
- These are transient tactile, visual, or auditory hallucinations in the setting of clear consciousness.
- Often in the form of a conversation in the second person and may be derogatory.

Delirium Tremens
- 50% will develop the symptoms within 46 hours
- 90% within 85 hours of admission to hospital.
- occurs in 20% of patients with alcohol withdrawal
- without treatment lasts 72 hours, and kills 15 - 20% of patients.

Higher Risk Patients include:
    Are over 70 years old
    Need invasive or non-invasive ventilation
    Present with seizures on admission
    Are admitted to hospital with other complications, for example cerebral injury or hypoxia
    Have a delay of more than 24 hours prior to treatment.

Signs and symptoms of DT
    Excessive sweating
    Profound agitation
    A fever greater than 38.5°C
    Tachycardia - a heart rate of greater than 100 beats a minute.

I can't find the evidence for this, but there is a suggestion we should do a full biochemical screen on all patients presenting with alcohol withdrawal:
    Blood glucose
    Full blood count
    Urea and electrolytes
    Clotting screen
    Liver function tests.
    Refer to gastro if suspected ALD - may need USS

Reduce sensory deprivation and treat the patient as you would normal delirium - manage in a side room, supportive care with supportive nursing staff, reassure the patient, regular observation.

Chlordiazepoxide 25 mg to 50 mg, using the CIWA scale:
    A score of 0 to 9 - you do not need to start treatment
    A score of 10 to 14 - give 25 mg of chlordiazepoxide
    A score of 15 or more - give 50 mg of chlordiazepoxide

In the presence of seizures:
    Intravenous diazepam at a rate of 2 mg a minute to a maximum dose of 10 mg to 20 mg
    Intravenous lorazepam at a rate of 2 mg a minute to a maximum dose of 4 mg to 8 mg.

Thiamine to all patients with actual or suspected alcohol dependence.

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