MANAGEMENT
OF THE INJURED
PATIENT IN
ALCOHOL
WITHDRAWAL
December 5, 2013
Saving Lives By Strengthening Our Region’s Trauma Care System
OBJECTIVES
1. Learn how to identify, assess and manage a
patient in alcohol withdrawal.
2. Develop an understanding and use of evidencebased tools used to monitor and assess the
severity of alcohol withdrawal (e.g. CIWA-Ar)
3. Obtain a basic understanding and knowledge to
safely and effectively identify, monitor and manage
alcohol withdrawal.
OUTLINE
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Diagnostic Criteria
Pathophysiology
Manifestations / Signs and Symptoms
Assessment
–Assessment Tools
• Management
–Pharmacological
–Nursing
• Case Study / Review
• CIWA-Ar in practice…
FACTS / STATISTICS
• There are approximately 8 million
people in the United States that
are dependent on alcohol.
–Alcohol is the most prevalent
addictive disorder in our country.
• 20% of all hospital admissions
are related to alcohol use/abuse.
• Every fifth patient admitted to a
hospital is an alcohol abuser;
–Among patients admitted for
abdominal surgery or trauma, the
prevalence soars to one out of
two.
DEFINITIONS
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Alcohol abuse
Alcohol dependence
Alcohol withdrawal syndrome (AWS)
Delirium tremens (DTs)
Alcohol hallucinosis
Alcohol withdrawal seizures
Wernicke’s syndrome
Korsakoff’s psychosis
NOTE: Nurses need to understand
these terms in order to be proactive
in managing the care of a patient who
has a problem with alcohol.
DIAGNOSTIC CRITERIA FOR ALCOHOL
WITHDRAWAL
DSM-IV Criteria for Alcohol Withdrawal :
• Cessation of (or reduction in) alcohol use that has been heavy and
prolonged.
• Two (or more) of the following, developing with several hours to a few days
after Criteria A:
– Autonomic hyperactivity (e.g. sweating or pulse rate great than 100)
– Increased hand tremor
– Insomnia
– Nausea or vomiting
– Transient visual, tactile, or auditory hallucinations or illusions
– Psychomotor agitation
– Anxiety
– Grand mal seizures
• The symptoms in Criteria B cause clinically significant distress or impairment
in social, occupational, or other important areas of functioning.
• The symptoms are not due to a general medical condition and are not better
accounted for by another mental disorder
PATHOPHYSIOLOGY
• Alcohol is a central nervous system depressant
–Enhances (the neurotransmitter) GABA
–Inhibits (the amino acid) glutamate
• The persistent presence of alcohol allows the maintaining
of balance between these two substances
• The ABRUPT cessation of alcohol disrupts this balance
and causes over-activity of the central nervous system
leading to the manifestations of AWS
• When alcohol cessation occurs, one can substitute a
barbiturate or benzodiazepine to maintain the same
inhibitory effect
–A process called “cross tolerance”
–The foundation of managing a patient experiencing alcohol
withdrawal
MANIFESTATIONS / SIGNS AND SYMPTOMS
• Alcohol affects every system in the
body
– It is absorbed in the stomach and upper
intestine, and then quickly passes through
the bloodstream; and within minutes, it
permeates the brain, liver, heart,
pancreas, lungs and kidneys!
• Alcohol depresses the central
nervous system
• The brain regulates almost every
mechanism of the body, including:
– B/P, HR, temperature, mood, perception,
movement, balance
• Once alcohol is removed – every
mechanism will over-react within
hours of the last drink!
Abrupt withdrawal from
alcohol use most
immediately affects the
brain.
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
Alcohlic hallucinosis: visual, auditory, or
tactile hallucinations
(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)
Withdrawal seizures: generalizaed tonicclonic seizures
Alcohol withdrawal delirium (delirium
tremens): hallucinations (predominately
visual), disorientation, tachycardia,
hypertension, low-grade fever, agitation,
diaphoresis
MANIFESTATIONS / SIGNS AND SYMPTOMS
CONT’D.
• Severity of withdrawal is directly related to the
QUANTITY of alcohol intake and the CHONCITY
(frequency) of alcohol abuse.
• Multiple episodes of AWS lead to increased
sensitivity, resulting in a process called
“kindling.”
• Each time a person goes through the
withdrawal process, the symptoms are more
intense and the duration of the withdrawal is
longer
MANIFESTATIONS / SIGNS AND SYMPTOMS
CONT’D.
• It is difficult to accurately predict which patient will develop which
withdrawal symptoms
• Risk factors for SEVERE withdrawal include:
– High levels of alcohol intake
– Long duration
– Prior AW symptoms
– Abnormal liver function
– Older age
– Poor general health
– Poor nutritional status
– Additional substance abuse
NOTE: There are several medical problems that can be misinterpreted as
AWS, and include: Infection, head trauma, fluid and electrolyte
imbalances, drug overdose, benzodiazepine withdrawal, dementia,
internal bleeding, atrial fibrillation, and liver failure
ASSESSMENT
• ALL patients admitted to a hospital should be
assessed for alcohol consumption
• The omission of alcohol use can have
disastrous consequences!
• An accurate alcohol use history should include:
–Frequency
–Quantity
–Length/duration
–Most recent use
ASSESSMENT TOOLS
• The CAGE Questionnaire
–Demonstrated to be a reliable and valid tool in clinical
settings
–Allows nurses to assess alcohol consumption in a nonconfrontational manner by asking four questions
• Two or more positive responses to the questions may
indicate alcohol dependence and a risk of AWS
THE CAGE QUESTIONNAIRE
More than two positive responses to the questions
suggest alcohol dependence and indicate further
assessment is warranted.
1. Have you ever felt you ought to Cut down on your
drinking?
2. Have people Annoyed you by criticizing your drinking?
3. Have you ever felt Guilty about your drinking?
4. Have you ever had a drink first thing in the morning to
steady your nerves or to get rid of a hangover (Eyeopener)?
CLINICAL INSTITUTE WITHDRAWAL ASSESSMENT
FOR ALCOHOL-REVISED
(CIWA-AR)
• Documented as a reliable and valid assessment tool for individuals
experiencing either minor or severe AWS (no copyright)
• Consists of multiple rating scales covering 10 assessment areas:
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Nausea and vomiting
Tremor
Paroxysmal sweats
Anxiety
Tactile disturbances
Auditory disturbances
Visual disturbances
Headache, fullness in the head
Agitation
Orientation and clouding of sensorium
CIWA-AR
• Can be completed relatively quickly, usually within 2-5
minutes
• Allows nurses to quantify the potential for the
development of AWS
–Implement/apply the appropriate interventions (e.g. medication)
• Reassessment at appropriate intervals monitors the
response to treatment and the need for additional
medication to control symptoms
• Maximum possible score = 67, with medication being
required when the patient has a score greater than 8
–< 8 indicates mild withdrawal
–9-15 indicates moderate withdrawal
–> 15 indicates severe withdrawal
MANAGEMENT
GOALS:
• To provide a safe withdrawal process
– Preserve respiratory and cardiac function
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Alleviate symptoms
Prevent DT’s and seizures
Maintain the individual’s dignity
Coordinate follow-up treatment in an outpatient setting
FOCUS:
• Rule out other possible causes of the patient’s condition
• Supportive care
• Control of symptoms
• Nutritional supplements
• Correcting fluid and electrolyte deficits
Timely intervention is critical!
PHARMACOLOGICAL MANAGEMENT
Benzodiazepines
• Examples:
– lorazepam (Ativan),
– chlordiazepoxide (Librium),
– valium (Diazepam)
• Recommended over other medications because they have better documented
efficacy, are safer, and are less likely to lead to abuse
– 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.
Benzodiazepines Most Commonly Used
for the Effective Management of Alcohol
Withdrawal
Ativan
Route
P.O.
I.V.
I.M.
(lorazepam)
Onset
1 hr
5 min
15-30 min
Librium
Route
P.O.
(chlordiazepodie hydrochloride)
Onset
Peak
Duration
Unknown
1/2-4 hr
Unknown
Valium
Route
P.O.
I.V.
I.M.
P.R.
(diazepam)
Onset
30 min
1-5 min
Unknown
Unknown
Peak
2 hr
60-90 min
60-90 min
Peak
2 hr
1-5 min
2 hr
90 min
Duration
12-24 hr
6-8 hr
6-8 hr
Duration
20-80 hr
15-60 min
Unknown
Unknown
PHARMACOLOGICAL MANAGEMENT
• The frequency and dose of medication is based on the patient’s CIWA-Ar
assessment score performed by the nurse
– Administration of IV benzodiazepines and/or severe AWS will require more frequent assessments
(e.g. q1 hour)
– Administration of oral benzodiazepines and/or mild to moderate AWS will require less frequent
assessments (e.g. q4-6 hours)
• 3 Dosing Regimens:
– Front loading
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providing a benzodiazepine prophylactically for patients at high risk for AWS and/or a history of severe
withdrawal (in absence of symptoms)
– Fixed schedule
– Symptom triggered
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Individualization of a symptom-triggered medication regimen leads to administration of LESS medication and a
SHORTER withdrawal period (as compared to a fixed-dose schedule)
“Giving patients what they need when they need it.”
NOTE: Benzodiazepine therapy should be symptom-drive – overmedicating
should be avoided, as it can lead to falls, prolonged sedation, and functional
deficits!
NURSING MANAGEMENT
• Decrease environmental stimuli
• Provide uninterrupted periods
of sleep/rest
• Avoid the use of restraints
– Worsen the neuropsychological
alterations
• Provide orientation
– Clocks
– Calendars
• Limit TV
– As it may contribute to confusion and
hallucinations
• Ensure adequate nutrition
• Monitor fluid balance (i.e.
input/output)
– Hydration (with decaffeinated fluids)
DISCHARGE PLANNING
•
Even if the patient does not seem
receptive to changing his/her drinking
behavior, YOU have a responsibility
to:
• Explain clearly and objectively the
connection between chronic alcohol
abuse, the disease state that brought
him/her to the hospital, and any alcoholrelated complications
• Offer information on treatment options
and sources of support.
• Express confidence in his/her ability to
change his/her drinking behavior.
Be non-judgmental, provide support
and encouragement!
CIWA-AR IN PRACTICE
• Putting it ALL together…
• If you are still feeling like you need more
information, check out the following
YouTube video:
• http://www.youtube.com/watch?v=VLmis4YDUI0
• U.C. San Diego Medical Center
QUESTIONS…
ANN BUNNELL, MSN, APNP, PMHCNS-BS
ABUNNELL@MHSJVL.ORG
JENNY KLEINERT, BSN, RN-BC, PMHN
JKLEINERT@MHSJVL.ORG
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.