Adult Alcohol Withdrawal Protocol Power Plan Draft
Note: Contraindications:
Less than 18 years of age
Intubated
Chemical Paralysis
Pregnancy
Allergy or Intolerance to lorazepam or chlordiazepoxide
Order Maintenance: Pharmacist/RN – Discontinue all existing benzodiazepine orders
Assessment and Monitoring
CIWA-Ar and vital signs at baseline
CIWA-Ar per protocol until all scores < 8 for a 24 hr period
Vital signs with each CIWA-Ar reassessment and per unit protocol
EKG at baseline and per unit protocol
Seizure Precautions
Neuro checks q shift and per unit protocol
CIWA-Ar score, assessment and treatment documented in eMAR
Hold doses for over sedation or somnolence
Strict I&O
Daily weight
Reference Link: CIWA-Ar Scale, see also Attachment #1
Laboratory:
Admission:
CBC once
Chem 7 once
LFT’s once
INR once
Ammonia once
Urine Drug Screen once
Blood Alcohol Level once
Serum Pregnancy test once (as applicable)
Daily:
CBC qAM x 3 days
Chem 7 qAM x 3 days
Notify LIP for:
Seizure
Aspiration
Cardiac arrhythmia
Unarousable patient
Restraints required
Approaching protocol maximum doses
CIWA-Ar score ≥18 for 2 consecutive hours despite treatment
Respiratory rate < 12 per minute
1:1 Nursing care required
CIWA-Ar < 8 for 24 hours
Medications:
Order Maintenance: Pharmacist/RN – Discontinue all existing benzodiazepine orders
Note: Dosing Based on CIWA score and patient condition. Select one condition only
Note: Hepatic Dysfunction – Defined as cirrhosis or Child-Pugh category B or C
Note: Renal Dysfunction – Defined as severe renal impairment, CrCl < 10 mL/min
Select ONE Condition ONLY – No Impairment OR Impaired see definitions
Note: Patient Condition No Impairment: Age <65, no hepatic or renal dysfunction,
non-neurology
CIWA score <8
Reassess in 4 hr or sooner for agitation
No treatment
CIWA score 8 – 11
Reassess q 2 hr and treat based on new CIWA score
Lorazepam 1 mg IVP q 2 hr prn (Max dose 12 mg/24 hr)
OR
Chlordiazepoxide 25 mg po q 2 hr prn (Max dose 150 mg/24 hr)
CIWA score 12 – 15
Reassess q 2 hr and treat based on new CIWA score
Lorazepam 2 mg IVP q 2 hr prn (Max dose 24 mg/24 hr)
OR
Chlordiazepoxide 50 mg po q 2 hr prn (Max dose 300 mg/24 hr)
CIWA score 15 – 16
Reassess q 1 hr and treat based on new CIWA score
Lorazepam 3 mg IVP q 1 hr prn (Max dose 24 mg/24 hr)
OR
Chlordiazepoxide 75 mg po q 2 hr prn (Max dose 300 mg/24 hr)
CIWA score 17 – 18
Reassess q 1 hr and treat based on new CIWA score
Lorazepam 4 mg IVP q 1 hr prn (Max dose 24 mg/24 hr)
OR
Chlordiazepoxide 100 mg po q 2 hr prn (Max dose 300 mg/24 hr)
CIWA-Ar score > 18
Notify LIP
Monitor continuously until CIWA-Ar < 18
Note: Patient Condition Impaired Dose Adjustment Required: Age >65 or hepatic or
renal dysfunction or neurology
CIWA score <8
Reassess in 4 hr or sooner for agitation
No treatment
CIWA score 8 – 11
Reassess q 2 hr and treat based on new CIWA score
Lorazepam 0.5 mg IVP/PO q 2 hr prn (Max dose 6 mg/24 hr)
CIWA score 12 – 15
Reassess q 2 hr and treat based on new CIWA score
Lorazepam 1 mg IVP/PO q 2 hr prn (Max dose 12 mg/24 hr)
CIWA score 15 – 16
Reassess q 1 hr and treat based on new CIWA score
Lorazepam 2 mg IVP/PO q 1 hr prn (Max dose 24 mg/24 hr)
CIWA score 17 – 18
Reassess q 1 hr and treat based on new CIWA score
Lorazepam 3 mg IVP/PO q 1 hr prn (Max dose 24 mg/24 hr)
CIWA-Ar score > 18
Notify LIP
Monitor continuously until CIWA-Ar < 18
Additional Medications:
Nausea and Vomiting:
1st choice: Ondansetron 4 mg IV/PO q 8 hr prn
2nd choice: Promethazine:
12.5 mg IV q 6 hr prn if ondansetron ineffective
25 mg po q 6 hr prn if ondansetron ineffective
3rd choice: Metoclopramide
10 mg IV/PO q 6 hr prn if promethazine ineffective
5 mg IV/PO q 6 hr prn if promethazine ineffective and renal
dysfunction
Fever or Headache:
CAUTION CALL LIP FOR HEPATIC DYSFUNCTION
Acetaminophen 650 mg PR/PO q 4 hr prn
Do not exceed 4 gram acetaminophen per day from all sources
Nutritional Supplements:
Patient npo:
NS 1000 mL
Multi vitamin injection 10 mL
Thiamine 100 mg
Folate 1 mg
One bag daily for 3 days
Oral intake allowed:
Multivitamin tablet 1 tab po daily
Thiamine 100 mg po daily
Folate 1 mg po daily
Agitation:
Haloperidol – not recommended in alcohol withdrawal
Lowers seizure threshold
Prolongs QT interval
Order only under discretion
Obtain EKG prior to ordering and administration
Notify LIP for:
Systolic blood pressure > than ____ mm Hg
Systolic blood pressure < than ____ mm Hg
Diastolic blood pressure > than ____ mm Hg
Heart Rate > than ____ beats per minute
Heart Rate < than ____ beats per minute
MAP > than ____ mm Hg
MAP < than ____ mm Hg
Attachment #1
CIWA-Ar Scale
ALCOHOL WITHDRAWAL SCALE CIWA-Ar
(Clinical Institute Withdrawal Assessment of Alcohol Scale, revised)
NAUSEA AND VOMITING – Ask “Do you feel sick to your stomach?
TACTILE DISTURBANCES – Ask “Have you any itching, pins and
Have you vomited?” Observation.
0 no nausea and no vomiting
1 mild nausea with no vomiting
2
3
4 intermittent nausea with dry heaves
5
6
7 constant nausea, frequent dry heaves and vomiting
needles sensations, any burning, any numbness, or do you feel bugs crawling on
or under your skin?” Observation.
0 none
1 very mild itching, pins and needles, burning or numbness
2 mild itching, pins and needles, burning or numbness
3 moderate itching, pins and needles, burning or numbness
4 moderately severe hallucinations
5 severe hallucinations
6 extremely severe hallucinations
7 continuous hallucinations
AUDITORY DISTURBANCES – Ask “Are you more aware of sounds
around you? Are they harsh? Do they frighten you? Are you hearing anything
that is disturbing to you? Are you hearing things you know are not there?”
Observation.
0 not present
1 very mild harshness or ability to frighten
2 mild harshness or ability to frighten
3 moderate harshness or ability to frighten
4 moderately severe hallucinations
5 severe hallucinations
6 extremely severe hallucinations
7 continuous hallucinations
VISUAL DISTURBANCES – Ask “Does the light appear to be too bright?
Is its color different? Does it hurt your eyes? Are you seeing anything that is
disturbing to you? Are you seeing things you know are not there?” Observation.
0 not present
1 very mild sensitivity
2 mild sensitivity
3 moderate sensitivity
4 moderately severe hallucinations
5 severe hallucinations
6 extremely severe hallucinations
7 continuous hallucinations
HEADACHE, FULLNESS IN HEAD – Ask “Does your head fee
different? Does it feel like there is a band around your head?”
Do not rate for dizziness or lightheadedness. Otherwise, rate severity.
0 not present
1 very mild
2 mild
3 moderate
4 moderately severe
5 severe
6 very severe
7 extremely severe
ORIENTATION AND CLOUDING OF SENSORUM – Ask “What
day is this? Where are you? Who am I?”
0 oriented and can do serial additions
1 cannot do serial additions or is uncertain about date
2 disoriented for date by no more than 2 calendar days
3 disoriented for date by more than 2 calendar days
4 disoriented for place/or person
TREMOR – Arms extended and fingers spread apart.
Observation
0 no tremor
1 not visible, but can be felt fingertip to fingertip
2
3
4 moderate, with patient’s arms extended
5
6
7 severe, even with arms not extended
PAROXYSMAL SWEATS – Observation.
0 no sweat visible
1 barely perceptible sweating, palms moist
2
3
4 beads of sweat obvious on forehead
5
6
7 drenching sweats
ANXIETY – Ask “Do you feel nervous?” Observation.
0 no anxiety, at ease
1 mild anxious
2
3
4 moderately anxious, or guarded, so anxiety is inferred
5
6
7 equivalent to acute panic states as seen in severe delirium or acute
schizophrenic reactions
AGITATION – Observation.
0 normal activity
1 somewhat more than normal activity
2
3
4 moderately fidgety and restless
5
6
7 paces back and forth during most of the interview, or constantly
thrashes about
Sullivan, J.T.; Sykora, K.; Schneiderman, J.; Naranjo, C.A.; and Sellers,
E.M. Assessment of alcohol withdrawal: The revised Clinical Institute
Withdrawal Assessment of Alcohol scale (CIWA-Ar). British Journal of
Addiction 84:1353-1357; 1989.
Total CIWA-Ar Score __________________
Rater’s Initials __________________
Maximum Possible Score 67