Alcohol Withdrawal
Management
Erum Iqbal Bajwa
Updated June 2015
Objectives
Discuss the signs and symptoms of alcohol withdrawal
Discuss the components of the revised Clinical Institute
Withdrawal Assessment of Alcohol (CIWA-Ar) score
Discuss the identification of delirium tremens
Discuss when to send a patient to the Intensive Care Unit with
severe alcohol withdrawal
Discuss the management of alcohol withdrawal on the inpatient
ward floor
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Case 1
70-yo M with unknown PMHx was brought into ED after being
found down. Pt was found to have displaced hip fracture and was
taken to OR for ORIF. Pt initially did well post-op, but 48 hrs after
admission pt started having tachycardia, hypertension, fever, and
agitation.
What are some differential diagnosis?
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What are the stats?
• There are an estimated 8 million people in the US dependent
on alcohol
• 500,000 people per year are admitted for pharmacological
management of alcohol withdrawal
• Mild to moderate symptoms begin as early as 6 hours after the
last drink
•
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Most vulnerable patients are those have had long and
sustained periods of drinking with abrupt cessation. Binge
drinkers are less at risk.
Signs and Symptoms of Alcohol Withdrawal
The signs and symptoms of alcohol withdrawal include but are not
limited to:
• Nausea/vomiting and generalized GI symptoms
• Tactile disturbances
• Auditory and visual hallucinations
• Tremors or tremulousness
• Diaphoresis
• Anxiety and agitation
• Headache
• Altered Mental Status, Disorientation
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What is the CIWA-Ar score?
• A score of 0 – 7 is given for 9 components and 0-4 for 1 component
A sum total of the 10 components score is calculated for a CIWA-Ar Score
Symptom
CIWA-Ar Scale Description
Nausea/vomiting
0- none; 1- mild nausea, no vomiting;
4- intermittent nausea; 7- constant nausea, frequent
dry heaves & vomiting.
“Is your stomach upset?”
Tremors
0- no tremor; 1- not visible but can be felt;
4- moderate w/ arms extended; 7 - severe, even w/
arms not extended.
Anxiety
0- none, at ease; 1- mildly anxious; 4- moderately
anxious or guarded; 7- equivalent to acute panic state
Agitation
0 - normal activity; 1 - somewhat normal activity; 4 moderately fidgety/restless; 7 - paces or constantly
thrashes about
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CIWA-Ar Score
Symptom
CIWA-Ar Scale Description
Paroxysmal Sweats
0- no sweats; 1- barely perceptible
sweating, palms moist; 4- beads of sweat
obvious on forehead; 7- drenching sweat
Orientation (0-4)
0- oriented; 1- uncertain about date; 2disoriented to date by no more than 2
days; 3- disoriented to date by > 2 days;
4- disoriented to place and/or person
Ask, “What day is this?
Where are you? Who am I?”
Tactile Disturbances
Ask, “Have you experienced any itching, pins &
needles (P&N) sensation, burning or numbness,
or a feeling of bugs crawling on or under your
skin?”
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0- none; 1- very mild itch, P&N, numbness;
2- mild itch, P&N, burning, numbness; 3moderate itch, P&N, burning, numbness;
4- moderate hallucinations; 5- severe
hallucinations; 6- extremely severe
hallucinations; 7- continuous
hallucinations
CIWA-Ar Score
Symptom
CIWA-Ar Scale Description
Auditory Disturbances
0- not present; 1- very mild harshness/
ability to startle; 2- mild harshness, ability
to startle; 3- moderate harshness, ability to
startle; 4- moderate hallucinations; 5severe hallucinations; 6- extremely severe
hallucinations; 7- continuous hallucinations
Ask, “Are you more aware of sounds around
you? Are they harsh? Do they startle you? Do
you hear anything that disturbs you or that you
know isn’t there?”
Visual Disturbances
0 - not present; 1- very mild sensitivity;
Ask, “Does the light appear to be too bright? Is
2- mild sensitivity; 3- moderate sensitivity;
its color different than normal? Does it hurt your 4- moderate hallucinations; 5- severe
eyes? Are you seeing anything that disturbs you
hallucinations; 6- extremely severe
or that you know isn’t there?”
hallucinations; 7- continuous hallucinations
Headache
Ask, “Does your head feel different than usual?
Does it feel like there is a band around your
head?”
Do not rate dizziness or lightheadedness.
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0- not present; 1- very mild; 2- mild; 3moderate; 4- moderately severe; 5- severe;
6- very severe; 7- extremely severe
Explanation of the CIWA-Ar Score
Scale for Scoring:
Total Score =
0 – 9: absent or minimal withdrawal
10 – 19: mild to moderate withdrawal
> 20: severe withdrawal
• Prophylactic medication should be started for any patient with
a total CIWA-Ar score of 8 or greater
• Total CIWA-Ar score 15 or higher should be on scheduled
medication (Scheduled + PRN for breakthrough method) and
reassessment every hour for at least 8 hours until score is < 8.
• Consider transfer to ICU if score > 35
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What is Delirium Tremens?
• The most severe form of alcohol withdrawal
manifested by altered mental status and autonomic
hyperactivity which can progress to cardiovascular
collapse
• Signs and Symptoms: (in addition to those of basic
alcohol withdrawal)
• Hypertension
• Tachycardia
• Hyperthermia
• Severe Agitation
• Diaphoresis
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Delirium Tremens
• Approximately 5% of drinkers are at risk for delirium tremens
• DTs usually manifest 48-96 hours after last drink
• DT is associated with mortality rate of up to 5% (significantly
reduced from 37% in the early 20th century)
• Arrhythmias are the most common cause of death in DTs
• Greater mortality with older age, preexisting pulmonary disease and
liver disease
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Withdrawal symptoms timeline
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Watch Out For!!
• Hypovolemia- result of diaphoresis, hyperthermia, vomiting,
tachypnea
• Hypokalemia – due to renal and extra-renal potassium losses,
alterations in aldosterone levels, changes in cellular potassium
distribution
• Hypomagnesaemia- predisposes patients to arrythmias and
seizures
• Hypophosphatemia
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Case 2
40-yo M with h/o alcohol abuse presented with palpitations,
nausea/ vomiting, and tremors.
Patient drinks half a pint of vodka daily and reports that his last
drink was approximately 12 hours prior to admission. On further
questioning, pt reports history of alcohol withdrawal seizures and
has been admitted to OSH ICUs in the past for alcohol withdrawal.
In the ED, patient is tremulous, afebrile, has regular tachycardia,
slightly hypertensive.
Q: Where should this patient be managed?
a.) Medicine Floor
b.) Intensive Care Unit
c.) Discharged Home
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ICU Admission Criteria
•
Active Seizures
• Any suspicion for DTs:
• ALL alcohol withdrawal symptoms PLUS:
•
•
•
•
•
Hypertension
Tachycardia
Hyperthermia- persistent
Severe Agitation
Diaphoresis
• CIWA-Ar Score > 35 on admission or q1h assessments required for
more than 8 hrs
• More than 4 mg/hr IV Lorazepam for 3hr or 20 mg/hr IV Diazepam for
3hr
• Hemodynamic instability or respiratory distress
• Severe electrolyte or acid/base disturbances
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Alcohol Withdrawal
Management
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What’s in Quest CIWA order set?
• Vital signs q4h if CIWA < 10, otherwise every 1 hour assess
patient
•
Cardiac monitoring, continuous pulse oximetry, fall/seizure/
aspiration precautions, labs, imaging
• Medications: are based on CIWA-Ar Score previously discussed
• If NPO- Lorazepam (or Diazepam may be used)
•
•
•
PRN IV Lorazepam 2mg q2h for CIWA-Ar <10
PRN IV Lorazepam 2mg q1h for CIWA-Ar 10-15
PRN IV Lorazepam 4mg q1h for CIWA-Ar > 15
• If taking PO, Chlordiazepoxide
• DO NOT order both
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What’s in Quest CIWA order set?
• Multivitamins:
• If NPO: “Banana bag”: NS with 100mg thiamine, 1g folate, and
multivitamin
• If can take PO, order PO vitamins
• No increased benefit of infusion, if can take PO give them PO
vitamin replacement
• Case Management Referral for discharge planning
• Social Work referral
• Dietitian referral
• Psych consult for alcohol dependence
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Not in the order set?
• Electrolyte levels
• Electrolyte repletion
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Post Test:
Which protocol do you initiate to monitor and manage alcohol
withdrawal symptoms?
Which electrolytes do you check specifically in alcohol withdrawal
management?
What IVF and medications do you order?
At what time mark past the last drink is the patient at greatest risk
for alcohol withdrawal seizures? For DTs?
Under what circumstances would you call the ICU?
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Post Test:
Which protocol do you initiate to monitor and manage alcohol
withdrawal symptoms? CIWA-Ar Protocol
Which electrolytes do you check specifically in alcohol withdrawal
management? Mag, Phos, K
What IVF and medications do you order? Banana Bag, IV
Lorazepam
At what time mark past the last drink is the patient at greatest risk
for alcohol withdrawal seizures? 6-48 hours For DTs? 48-96 hrs after
last drink.
Under what circumstances would you call the ICU?
• Total CIWA-Ar score above 35
• q1h assess required for more than 8 hrs,
• more than 4 mg/hr IV Lorazepam for 3hr or 20 mg/hr Diazepam for 3hr
• Respiratory Distress, suspicion for DTs
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Summary
• Withdrawal symptoms can start as early as 6 hours from the
last drink. It is always important to ask when the last drink was
taken.
• Use the CIWA-Ar Score on admission to help determine the
patient’s severity of alcohol withdrawal
• Management of moderate-severe alcohol withdrawal, includes:
IV fluid, IV vitamins, and PRN IV lorazepam or diazepam.
• Don’t forget to check and replace electrolytes
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References
Hoffman RS, Weinhouse GL. Management of moderate and severe alcohol
withdrawal syndromes. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA.
(Accesseed on June 5, 2015)
Sullivan JT, Sykora K, Schneiderman J, Naranjo CA, Sellers EM. Assessment of alcohol
withdrawal: the revised clinical institute withdrawal assessment for alcohol scale
(CIWA-Ar). Br J Addict. 1989 Nov;84(11):1353-7. PubMed PMID: 2597811.
Stephens JR, Liles EA, Dancel R, et al. Who needs inpatient detox? Development and
implementation of a hospitalist protocol for the evaluation of patients for alcohol
detoxification. J Gen Intern Med. 2013; doi:10.1007/ s11606-013-2571-5.
Nuss MA, Elnicki DM, Dunsworth TS, Makela EH. Utilizing CIWA-Ar to assess use of
benzodiazepines in patients vulnerable to alcohol withdrawal syndrome. W V Med
J. 2004 Jan-Feb;100(1):21-5. PubMed PMID: 15119493.
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