Showing posts with label withdrawal. Show all posts
Showing posts with label withdrawal. Show all posts

Friday, 8 January 2021

WHO 2012 Guidelines for the Treatment of Alcohol Withdrawal

WHO 2012 Guidelines to treat Alcohol Withdrawal

  1. Clinicians should advise supported withdrawal in patients before beginning treatment.
  2. The World Health Organization recommends benzodiazepines as front-line medication for the management of alcohol withdrawal. 
  3. Long-acting benzodiazepines are superior to shorter-acting ones, except in cases of impaired hepatic metabolism. 
  4. Clinicians should determine the dose and duration individually. 
  5. The duration of benzodiazepine treatment should be 3 to 7 days.
  6. Clinicians should not use antipsychotic medications as stand-alone medications for the management of alcohol withdrawal. 
  7. Advise Benzodiazepines, and not anticonvulsants, following an alcohol withdrawal seizure.
  8. Clinicians should dispense psychoactive medication in small doses.  
  9. Patients at risk of severe withdrawal, or who have concurrent serious physical or psychiatric disorders, or who lack adequate support, should preferably remain in an inpatient setting. 
  10. As part of withdrawal management, we should give all patients oral thiamine. 
  11. Patients at high risk of Wernicke's Encephalopathy (malnourished, severe withdrawal) should be given 3 days of parental thiamine. 

Thursday, 7 January 2021

Sample CASC-Opiate (opioid) Withdrawal Assessment

Opiate Withdrawal History and Physical Examination 

Opiate withdrawal symptoms peak between 36-72 hours. Symptoms run their course in 5-7 days, though craving continues for some time. 

Withdrawal from Heroin

Withdrawal from heroin may begin up to 8 hours after the last use. During the next few hours, the person experiences muscle pain, sneezing, sweating; tearfulness; yawning excessively. At 36 hours after the last use, symptoms are most severe. These symptoms include chills, muscle cramps, flushing, sweating, tachycardia, hypertension, inability to sleep, vomiting & diarrhoea. Symptoms typically continue for about 72 hours & gradually diminish over 5-10 days.

History 

This history part is in Urdu/Hindi. I will add the "Objective Opiate Withdrawal Scale" soon here so anyone can benefit.
 
For now: COWS 

  1. Aap kia istemal karty
  2. Akhri bar kab lia hai aap ne
  3. Abhi dil chahta ke aap dobara se kar lyn? Kitna had tak? 
  4. Gutno ya baqi jorhon mai dard ho raha hai? Baqi jisam or pat’tho mai takleef? Sar dard? 
  5. Pait ma dard waghera? Ulti ya matli to nai arhaii? Pechas ya ihsal ki shikayat?
  6. Hot and cold flushes? 
  7. Cheenk to naii a rahy baar baar?
  8. Nend kesi hai? Araam se soe rehty han?   
  9. Koi bechainee, pareshani ki keffyat ya ghussa ata ho?  

Physical examination

Start from the hands. 
  1. Inspect the hands and run a hand over the palm. Note any sweating or palmar erythema. 
  2. Note if there is any piloerection if hair visible on the dorsal side of the hands. 
  3. Then check the pulse. 
  4. Inspect the arms for any signs of IV drug abuse. 
  5. Check blood pressure, and then check the temperature. 
  6. Check respiratory rate while checking the above. 
  7. Inspect the face for lacrimation, rhinorrhea and check pupil size for dilation. 
  8. Comment if the patient is shaking or yawning. 
  9. Perform a cardiovascular examination and look for murmurs. 
  10. Examine for the signs of liver failure

Clinical Vignette: Preventing Complication in A Man with Agitation

Clinical Vignette: Preventing Complication in A Man with Agitation

A 30-year-old man, who is a heavy alcohol drinker, presented to the emergency department with agitation, altered sensorium, marked tremors, visual hallucinations. On assessment, he is unaware of the time, place, and person. His blood pressure and pulse were 160/11 and 115/min on arrival but fluctuated on monitoring. A GP had given him haloperidol IM and diazepam IV to control his behavioral disturbance. 

What treatment-complication could arise?

a)       Seizures
b)      Over-sedation
c)       Respiratory depression
d)      Arrhythmia
e)       Worsening agitation


Benzodiazepines for the Treatment of Catatonia
Safest Treatment Option for Delirium Tremens
WHO Alcohol Withdrawal Treatment Guidelines

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