Days 1 and 2
20–30 mg qds
Days 3 and 4
15 mg qds
Day 5
10 mg qds
Day 6
10 mg bd
Day 7
10 mg nocte
Naltrexone may decrease alcohol consumption in people with alcohol dependency, but their compliance with treatment appears problematic.
Dispensing should be daily or involve the support of family members to prevent the risk of misuse or overdose. Confirm abstinence by checking the breath for alcohol or using a saliva test or Breathalyzer for the first 3–5 days.
Thiamine (150 mg per day in divided doses) should be given orally for 1 month. Transfer patient immediately to a general hospital or clinic with appropriate resuscitation facilities for parenteral supplementation if anyone of the following is present: ataxia, confusion, memory disturbance, delirium tremens, hypothermia and hypotension, ophthalmoplegia, or unconsciousness.
Daily supervision is essential in the first few days, then advisable thereafter, to adjust dose of medication, assess whether the patient has returned to drinking, check for serious withdrawal symptoms, and maintain support.
Patients requiring management of alcohol withdrawal with any of the following complications should be managed in an inpatient setting (see Table 77.2).
Table 77.2
Reasons for admission to a general medical hospital/ward
Admission to a general medical hospital/ward | |
|---|---|
Complication | Specific element |
Category | |
Complication obtained from the previous history | Previous complicated withdrawal (e.g., delirium tremens, alcohol hallucinosis) |
Previous convulsions or other complications during withdrawal | |
Recent loss of consciousness | |
Comorbid psychoactive substance abuse | |
Complications related to alcohol | Severe state of intoxication |
Markedly excessive alcohol use: the more potent the alcohol, the more frequent the use, and the longer it lasted, the more likely is complicated withdrawal | |
No or insignificant relief 2 h following the first outpatient benzodiazepine dose | |
Complicating physical features | Malnutrition |
Fever | |
Hypothermia | |
Dehydration | |
Jaundice | |
Severe tremors | |
Signs of significant trauma, especially head trauma | |
Specific organ failure | |
Acute abdominal signs | |
Gastrointestinal bleeding | |
Localizing neurological features | |
Wernicke’s encephalopathy | |
Presence of other medical or surgical conditions or the use of medication likely to complicate withdrawal management | |
Complications related to the mental status examination | Clouding of consciousness |
Delirium | |
Complications related to the financial/socioeconomic status of the patient | Patients who do not have the financial/social resources to cope with outpatient detoxification |
77.2 Common Trauma-Related Psychological Disorders
77.2.1 Trauma- and Stress-Related Disorders
- (a)
Acute stress reaction
For acute stress reaction (ASR), symptoms develop within minutes of a traumatic event and last up to hours or days. Although ASR is identified as a diagnosable disorder in ICD-10, it could more appropriately be considered a normal response to psychological trauma (as it remits naturally within hours or days), whereas acute stress disorder (ASD) and posttraumatic stress disorder (PTSD) are more abnormal responses.
- (b)
Acute stress disorder
According to DSM 5 [6], “acute stress disorder is diagnosed when an individual has been exposed to a traumatic event in which both of the following were present:
The person experienced, witnessed, or was confronted with (e.g., can include learning of) an event or events that involved actual or threatened death or serious injury or a threat to the physical integrity of self or others.
Though not required, the person’s response is likely to involve intense fear, helplessness, or horror.
Either while experiencing or after experiencing the distressing event, the individual has three or more of the following dissociative symptoms:
A subjective sense of numbing, detachment, or absence of emotional responsiveness
A reduction in awareness of his or her surroundings (e.g., “being in a daze”)
Derealization
Depersonalization
Dissociative amnesia (i.e., inability to recall an important aspect of the trauma)
The traumatic event is persistently reexperienced in at least one of the following ways: recurrent images, thoughts, dreams, illusions, flashback episodes, or a sense of reliving the experience or distress on exposure to reminders of the traumatic event.Related posts:
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