Alcohol WithdrawalAlcohol Withdrawal

Screening and TreatmentScreening and Treatment

BackgroundBackground

We have patients that come to We have patients that come to the hospital to have alcohol the hospital to have alcohol detoxification and receive help detoxification and receive help for their disease.for their disease.

We also have patients that We also have patients that come to the hospital for another come to the hospital for another reason such as a fractured hip, reason such as a fractured hip, but there is also an addiction to but there is also an addiction to alcohol.alcohol.

Studies on alcohol withdrawal Studies on alcohol withdrawal estimate that up to 40% of estimate that up to 40% of hospitalized patients have the hospitalized patients have the potential to experience alcohol potential to experience alcohol withdrawal syndrome. withdrawal syndrome.

Our current means of assessing Our current means of assessing for alcohol consumption and for alcohol consumption and treating alcohol withdrawal is not treating alcohol withdrawal is not standardized.standardized.

For most people who drink, alcohol For most people who drink, alcohol is a pleasant addition to eating and is a pleasant addition to eating and to other social activities.to other social activities.

For most adults drinking a moderate For most adults drinking a moderate amount of alcohol (up to 2 drinks per amount of alcohol (up to 2 drinks per day for men, and one drink per day day for men, and one drink per day for women and older people) is not for women and older people) is not harmful. However, some people get harmful. However, some people get into serious trouble because of their into serious trouble because of their drinking.drinking.

Evidence Based PracticeEvidence Based Practice

““CAGE Tool”CAGE Tool”This assessment tool will determine alcohol use and This assessment tool will determine alcohol use and possible dependency.possible dependency.

This tool has been used in multiple studies and has This tool has been used in multiple studies and has documented reliability and validity in clinical documented reliability and validity in clinical settings. The advantage to using CAGE is that it is settings. The advantage to using CAGE is that it is quick, easy to use, and easy to score.quick, easy to use, and easy to score.

Guidelines suggest that patients with a CAGE score Guidelines suggest that patients with a CAGE score greater than 2 should be considered alcohol greater than 2 should be considered alcohol dependent and at risk for developing alcohol dependent and at risk for developing alcohol withdrawal syndrome (AWS).withdrawal syndrome (AWS).A score of 1 or greater indicates a possible alcohol A score of 1 or greater indicates a possible alcohol dependency.dependency.

CAGE AssessmentCAGE Assessment

This short assessment will help This short assessment will help you determine if your patient you determine if your patient might have a problem with might have a problem with alcohol. The name “CAGE” is alcohol. The name “CAGE” is an acronym formed by taking an acronym formed by taking the first letter of key words from the first letter of key words from each of the following questions:each of the following questions:

CAGE AssessmentCAGE Assessment

Have you ever felt you should cut Have you ever felt you should cut down on your drinking?down on your drinking?

Have people annoyed you by Have people annoyed you by criticizing your drinking?criticizing your drinking?

Have you ever felt bad or guilty Have you ever felt bad or guilty about your drinking?about your drinking?

Have you ever had a drink first thing Have you ever had a drink first thing in the morning (as an “eye opener”) in the morning (as an “eye opener”) to steady your nerves or get rid of a to steady your nerves or get rid of a hangover?hangover?

CAGE AssessmentCAGE Assessment

This tool will be used in E.D. This tool will be used in E.D. triage and ambulatory surgery triage and ambulatory surgery screenings.screenings.

It will also be part of all It will also be part of all admission assessmentsadmission assessments

E.D. PatientsE.D. Patients

If your patient has a score of 1 or greater:If your patient has a score of 1 or greater: During business hours (M-F 7a.m.- 4:00 p.m.): During business hours (M-F 7a.m.- 4:00 p.m.):

ask the patient if he/she would like to see ask the patient if he/she would like to see someone from social services to discuss options someone from social services to discuss options for alcohol dependency. You do not need a for alcohol dependency. You do not need a physician’s order to make a referral to social physician’s order to make a referral to social services.services.

After hours: ask the patient if he/she would like After hours: ask the patient if he/she would like some information on services for alcohol some information on services for alcohol dependency and if the answer is yes, provide dependency and if the answer is yes, provide the patient with pamphlets that will be available the patient with pamphlets that will be available in the E.D.in the E.D.

Ambulatory Surgery PatientsAmbulatory Surgery Patients

If your patient has a score of 1 If your patient has a score of 1 or greater:or greater: ask the patient if he/she would like ask the patient if he/she would like

to see someone from social to see someone from social services to discuss options for services to discuss options for alcohol dependency. You do not alcohol dependency. You do not need a physician’s order to make need a physician’s order to make a referral to social services.a referral to social services.

Acute Care Patients Acute Care Patients

The CAGE assessment will be The CAGE assessment will be included in the nursing admission included in the nursing admission assessment.assessment.

If a patient has a score of 1 or If a patient has a score of 1 or higher:higher: Inform the physician that there is Inform the physician that there is

potential alcohol dependency with potential alcohol dependency with possibility of alcohol withdrawal possibility of alcohol withdrawal syndrome (AWS).syndrome (AWS).

Make a referral to social services (this Make a referral to social services (this does not require a physician order).does not require a physician order).

Signs and Symptoms of Signs and Symptoms of Alcohol WithdrawalAlcohol Withdrawal The mildest form of alcohol withdrawal The mildest form of alcohol withdrawal

includes symptoms due to increased CNS includes symptoms due to increased CNS and sympathetic activity. These usually and sympathetic activity. These usually consist ofconsist of AgitationAgitation Increased sweatingIncreased sweating TachycardiaTachycardia Increased hand tremorIncreased hand tremor GI upsetGI upset InsomniaInsomnia PalpitationsPalpitations HeadacheHeadache AnorexiaAnorexia

Alcoholic hallucinosis may also be Alcoholic hallucinosis may also be present in the form of transient present in the form of transient tactile, visual or auditory tactile, visual or auditory hallucinations, with visual being the hallucinations, with visual being the most common.most common.

Seizures may also occur and are Seizures may also occur and are usually generalized tonic-clonic usually generalized tonic-clonic convulsions occurring within the first convulsions occurring within the first 48 hours after the last drink.48 hours after the last drink.

The most severe form of alcohol The most severe form of alcohol withdrawal is delirium tremens withdrawal is delirium tremens (DT’s), which carries a mortality risk (DT’s), which carries a mortality risk of 1-5%of 1-5%

In-patients experiencing alcohol In-patients experiencing alcohol withdrawal have approximately a 5% withdrawal have approximately a 5% chance of developing DT’s.chance of developing DT’s.

Death, when it occurs in DT’s, is Death, when it occurs in DT’s, is usually due to arrhythmias or usually due to arrhythmias or complications from the DT’s, such as complications from the DT’s, such as pneumonia.pneumonia.

Risk Factors for Developing Risk Factors for Developing DT’sDT’s

History of sustained drinkingHistory of sustained drinking Age greater than 30Age greater than 30 History of previous DT’sHistory of previous DT’s Presence of concurrent illnessPresence of concurrent illness Greater number of days since Greater number of days since

last drinklast drink

Characteristic Features of Characteristic Features of DT’sDT’s

HallucinationsHallucinations DiaphoresisDiaphoresis AgitationAgitation Low grade feverLow grade fever TachycardiaTachycardia HypertensionHypertension DisorientationDisorientation

CIWA-Ar (Clinical Institute CIWA-Ar (Clinical Institute Withdrawal Assessment for Withdrawal Assessment for Alcohol Withdrawal – revised)Alcohol Withdrawal – revised) This is a scale to assess the physical and This is a scale to assess the physical and

psychological symptoms according to severity (“not psychological symptoms according to severity (“not present” to “extremely severe”) and medicate based present” to “extremely severe”) and medicate based on the objective data including:on the objective data including: AgitationAgitation AnxietyAnxiety Auditory disturbancesAuditory disturbances Clouding of the sensesClouding of the senses HeadachesHeadaches Nausea and vomitingNausea and vomiting Paroxysmal sweatsParoxysmal sweats Tactile disturbancesTactile disturbances TremorsTremors Visual disturbancesVisual disturbances

Once the data are collected, a Once the data are collected, a total score is obtained; the total score is obtained; the maximum score is 67maximum score is 67

The patient is medicated for The patient is medicated for alcohol withdrawal based on the alcohol withdrawal based on the score received.score received.

Studies on use of the CIWA-Ar have Studies on use of the CIWA-Ar have concluded:concluded: The CIWA-Ar is an effective guide in directing The CIWA-Ar is an effective guide in directing

medication administration.medication administration. Using the CIWA-Ar leads to an improvement in Using the CIWA-Ar leads to an improvement in

the appropriateness of pharmacotherapy without the appropriateness of pharmacotherapy without a difference in morbidity.a difference in morbidity.

When the scale is used, patients with a greater When the scale is used, patients with a greater dependence, and hence worse withdrawal dependence, and hence worse withdrawal receive greater amounts of medicine and vice receive greater amounts of medicine and vice versa. Thus, there is a titration of drug versa. Thus, there is a titration of drug administration to therapeutic requirement in a administration to therapeutic requirement in a more appropriate manner.more appropriate manner.

Studies on use of the CIWA-Ar Studies on use of the CIWA-Ar have concluded:have concluded: A lower average of medication A lower average of medication

used in the CIWA-Ar leads to used in the CIWA-Ar leads to financial savings without financial savings without increasing the rate of increasing the rate of complications.complications.

The use of the CIWA-Ar scale can The use of the CIWA-Ar scale can also help in writing the appropriate also help in writing the appropriate amount of prn medication.amount of prn medication.

CIWA-Ar CIWA-Ar

NAUSEA AND VOMITINGNAUSEA AND VOMITING-- Ask "Do you feel sick to your -- Ask "Do you feel sick to your stomach? Have you vomited?" stomach? Have you vomited?" Observation.Observation.

0 no nausea and no vomiting0 no nausea and no vomiting1 mild nausea with no vomiting1 mild nausea with no vomiting22334 intermittent nausea with dry heaves4 intermittent nausea with dry heaves55667 constant nausea, frequent dry heaves 7 constant nausea, frequent dry heaves and vomitingand vomiting

CIWA-ArCIWA-Ar

TACTILE DISTURBANCESTACTILE DISTURBANCES-- Ask "Have you any itching, pins and -- Ask "Have you any itching, pins and needles sensations, any burning, any numbness, or needles sensations, any burning, any numbness, or do you feel bugs crawling on or under your skin?” do you feel bugs crawling on or under your skin?” Observation.Observation.

0 none0 none1 very mild itching, pins and needles, burning or 1 very mild itching, pins and needles, burning or numbnessnumbness2 mild itching, pins and needles, burning or 2 mild itching, pins and needles, burning or numbnessnumbness3 moderate itching, pins and needles, burning or 3 moderate itching, pins and needles, burning or numbnessnumbness4 moderately severe hallucinations4 moderately severe hallucinations5 severe hallucinations5 severe hallucinations6 extremely severe hallucinations6 extremely severe hallucinations7 continuous hallucinations7 continuous hallucinations

CIWA-ArCIWA-Ar

TREMORTREMOR-- Arms extended and fingers spread apart. -- Arms extended and fingers spread apart. Observation.Observation.

0 no tremor0 no tremor1 not visible, but can be felt fingertip to 1 not visible, but can be felt fingertip to fingertipfingertip22334 moderate, with patient's arms extended4 moderate, with patient's arms extended55667 severe, even with arms not extended7 severe, even with arms not extended

CIWA-ArCIWA-Ar

AUDITORY DISTURBANCESAUDITORY DISTURBANCES-- Ask "Are you more aware of -- Ask "Are you more aware of sounds around you? Are they harsh? Do they sounds around you? Are they harsh? Do they frighten you? Are you hearing anything that is frighten you? Are you hearing anything that is disturbing to you? Are you hearing things you disturbing to you? Are you hearing things you know are not there?" know are not there?" Observation.Observation.

0 not present0 not present1 very mild harshness or ability to frighten1 very mild harshness or ability to frighten2 mild harshness or ability to frighten2 mild harshness or ability to frighten3 moderate harshness or ability to frighten3 moderate harshness or ability to frighten4 moderately severe hallucinations4 moderately severe hallucinations5 severe hallucinations5 severe hallucinations6 extremely severe hallucinations6 extremely severe hallucinations7 continuous hallucinations7 continuous hallucinations

CIWA-ArCIWA-Ar

PAROXYSMAL SWEATSPAROXYSMAL SWEATS-- Observation.-- Observation.

0 no sweat visible0 no sweat visible1 barely perceptible sweating, palms moist1 barely perceptible sweating, palms moist22334 beads of sweat obvious on forehead4 beads of sweat obvious on forehead55667 drenching sweats7 drenching sweats

CIWA-ArCIWA-Ar

VISUAL DISTURBANCESVISUAL DISTURBANCES-- Ask "Does the light appear to be too -- Ask "Does the light appear to be too bright? Is its color different? Does it hurt your eyes? bright? Is its color different? Does it hurt your eyes? Are you seeing anything that is disturbing to you? Are you seeing anything that is disturbing to you? Are you seeing things you know are not there?”Are you seeing things you know are not there?”Observation.Observation.

0 not present0 not present1 very mild sensitivity1 very mild sensitivity2 mild sensitivity2 mild sensitivity3 moderate sensitivity3 moderate sensitivity4 moderately severe hallucinations4 moderately severe hallucinations5 severe hallucinations5 severe hallucinations6 extremely severe hallucinations6 extremely severe hallucinations7 continuous hallucinations 7 continuous hallucinations

CIWA-ArCIWA-Ar

ANXIETYANXIETY-- Ask "Do you feel nervous?" Observation.-- Ask "Do you feel nervous?" Observation.

0 no anxiety, at ease0 no anxiety, at ease1 mild anxious1 mild anxious22334 moderately anxious, or guarded, so 4 moderately anxious, or guarded, so anxiety is inferredanxiety is inferred55667 equivalent to acute panic states as seen 7 equivalent to acute panic states as seen in severe delirium or in severe delirium or acute schizophrenic reactionsacute schizophrenic reactions

CIWA-ArCIWA-Ar

HEADACHE, FULLNESS IN HEADHEADACHE, FULLNESS IN HEAD-- Ask "Does your head feel -- Ask "Does your head feel different? Does it feel like there is a band around different? Does it feel like there is a band around your head?" Do not rate for dizziness or your head?" Do not rate for dizziness or lightheadedness. Otherwise, rate severity.lightheadedness. Otherwise, rate severity.

0 not present0 not present1 very mild1 very mild2 mild2 mild3 moderate3 moderate4 moderately severe4 moderately severe5 severe5 severe6 very severe6 very severe7 extremely severe7 extremely severe

CIWA-ArCIWA-Ar

AGITATIONAGITATION-- Observation.-- Observation.

0 normal activity0 normal activity1 somewhat more than normal activity1 somewhat more than normal activity22334 moderately fidgety and restless4 moderately fidgety and restless55667 paces back and forth during most of the 7 paces back and forth during most of the interview, or constantly interview, or constantly thrashes aboutthrashes about

CIWA-ArCIWA-Ar

ORIENTATION AND CLOUDING OF ORIENTATION AND CLOUDING OF SENSORIUMSENSORIUM-- Ask -- Ask "What day is this? Where are you? Who "What day is this? Where are you? Who am I?"am I?"

0 oriented and can do serial additions0 oriented and can do serial additions1 cannot do serial additions or is uncertain 1 cannot do serial additions or is uncertain about dateabout date2 disoriented for date by no more than 2 2 disoriented for date by no more than 2 calendar dayscalendar days3 disoriented for date by more than 2 3 disoriented for date by more than 2 calendar dayscalendar days4 disoriented for place/or person4 disoriented for place/or person

CIWA-ArCIWA-Ar

Total Total CIWA-ArCIWA-Ar Score Score ____________

Maximum Possible Score 67 Maximum Possible Score 67 The The CIWA-ArCIWA-Ar is not is not copyrighted and copyrighted and

may be reproduced freely. This may be reproduced freely. This assessment for monitoring assessment for monitoring withdrawal symptoms requires withdrawal symptoms requires approximately 5 minutes to approximately 5 minutes to administer. The maximum score is administer. The maximum score is 67 (see instrument). Patients scoring 67 (see instrument). Patients scoring less than 9 do not usually need less than 9 do not usually need additional medication for withdrawal. additional medication for withdrawal.

Management of Patients with Management of Patients with Alcohol Withdrawal SyndromeAlcohol Withdrawal Syndrome Most signs and symptoms of alcohol Most signs and symptoms of alcohol

withdrawal are caused by the rapid withdrawal are caused by the rapid removal of the depressant effects of removal of the depressant effects of alcohol in the central nervous alcohol in the central nervous system.system.

The cornerstone of pharmacological The cornerstone of pharmacological management for AWS patients is management for AWS patients is benzodiazepines. They reduce the benzodiazepines. They reduce the severity if the effects of alcohol severity if the effects of alcohol withdrawal and prevent progression withdrawal and prevent progression to the serious complications of AWS.to the serious complications of AWS.

HRH Alcohol Withdrawal HRH Alcohol Withdrawal ProtocolProtocol

The protocol has a stop date of 72 hours. The provider must assess need The protocol has a stop date of 72 hours. The provider must assess need and reorder if necessary.and reorder if necessary.

The following interventions are based upon the results of the CIWA-Ar The following interventions are based upon the results of the CIWA-Ar assessment scale.assessment scale.

Verify Verify date date (_______) and (_______) and time time (_______) of patient’s last alcohol consumption.(_______) of patient’s last alcohol consumption.Do notDo not initiate protocol if respiratory rate is less than 10 breaths/min. initiate protocol if respiratory rate is less than 10 breaths/min.Vital signs every 4 hours.Vital signs every 4 hours.Labs (if not drawn in ED): CBC, BMP, Protime/PTT, Mg, Phosphorus, Labs (if not drawn in ED): CBC, BMP, Protime/PTT, Mg, Phosphorus,

LFT’s,U/A, Urine drug screen, Urine HCG for women of childbearing age.LFT’s,U/A, Urine drug screen, Urine HCG for women of childbearing age.If patient is receiving benzodiazepines more often than every 2 hours –If patient is receiving benzodiazepines more often than every 2 hours –

continuous O2 sat monitor and telemetry.continuous O2 sat monitor and telemetry.Physician will order one of the following protocols:Physician will order one of the following protocols:

Lorazepam (Ativan) Protocol:CIWA-Ar ScoreLorazepam (Ativan) Protocol:CIWA-Ar ScoreLess than 9 pointsLess than 9 points NoneNone

9-10 points 1 mg IV, IM or PO (indicate route) every 60 min prn9-10 points 1 mg IV, IM or PO (indicate route) every 60 min prn 11-13 points 2 mg IV, IM or PO (indicate route) every 60 min prn 11-13 points 2 mg IV, IM or PO (indicate route) every 60 min prn

14-16 points 4 mg IV, IM or PO (indicate route) every 60 min prn14-16 points 4 mg IV, IM or PO (indicate route) every 60 min prn Greater than 16 points 5 mg IV, IM or PO (indicate route) Greater than 16 points 5 mg IV, IM or PO (indicate route) every 60 min prnevery 60 min prn

HRH Alcohol Withdrawal HRH Alcohol Withdrawal Protocol cont’dProtocol cont’d Chlorodiazepoxide (Librium) Protocol:CIWA-Ar Chlorodiazepoxide (Librium) Protocol:CIWA-Ar

Score:Score: Less than 9 pointsLess than 9 points NoneNone

9-10 points9-10 points 25 mg PO every 60 min prn25 mg PO every 60 min prn11-13 points11-13 points 50 mg PO every 60 min prn50 mg PO every 60 min prn14-16 points14-16 points 75 mg PO every 60 min prn75 mg PO every 60 min prn

Greater than 16 pointsGreater than 16 points 100 mg PO every 30 min prn100 mg PO every 30 min prnAnd notify providerAnd notify provider

Following initial CIWA-Ar scoring, repeat scoring:Following initial CIWA-Ar scoring, repeat scoring: every 4 hours if score is less than 9.every 4 hours if score is less than 9. if score is 9 or greater, medicate per protocol and if score is 9 or greater, medicate per protocol and

recheck score and reassess patient in 1 hour.recheck score and reassess patient in 1 hour.

HRH Alcohol Withdrawal HRH Alcohol Withdrawal Protocol cont’dProtocol cont’d Notify provider if:Notify provider if: Any CIWA-Ar score greater than 16 (also notify rapid Any CIWA-Ar score greater than 16 (also notify rapid

response team for score greater than16).response team for score greater than16). There is no improvement after four consecutive There is no improvement after four consecutive

assessments (including the baseline).assessments (including the baseline). The patient has received more than 6 mg of Lorazepam The patient has received more than 6 mg of Lorazepam

OR OR 300 mg of Librium in a 3 hour period.300 mg of Librium in a 3 hour period. Respiratory Rate is less than 10 breaths/min.Respiratory Rate is less than 10 breaths/min. Code green should be instituted for potentially violent Code green should be instituted for potentially violent

behavior.behavior. May discontinue protocol if the CIWA-Ar score is less than May discontinue protocol if the CIWA-Ar score is less than

8 for a 24 hour period in which no benzodiazepines were 8 for a 24 hour period in which no benzodiazepines were administered.administered.

Nurse Signature ___________________________Nurse Signature ___________________________Date/Time: ________________Date/Time: ________________

The alcohol withdrawal protocol The alcohol withdrawal protocol may be utilized on any patient may be utilized on any patient admitted (over the age of 18) admitted (over the age of 18) that is experiencing alcohol that is experiencing alcohol withdrawal, regardless if alcohol withdrawal, regardless if alcohol withdrawal is the primary withdrawal is the primary diagnosis.diagnosis.

Alcohol Withdrawal CaremapAlcohol Withdrawal Caremap

Patients who are admitted with a Patients who are admitted with a primary diagnosis of alcohol primary diagnosis of alcohol withdrawal will be placed on the withdrawal will be placed on the alcohol withdrawal Caremap.alcohol withdrawal Caremap.

Patients who are admitted with a Patients who are admitted with a primary diagnosis other than alcohol primary diagnosis other than alcohol withdrawal (e.g. fractured hip) but withdrawal (e.g. fractured hip) but are experiencing withdrawal, will are experiencing withdrawal, will have alcohol withdrawal added as a have alcohol withdrawal added as a secondary diagnosis.secondary diagnosis.

SummarySummary

HRH does not currently have a HRH does not currently have a standardized method of assessing for standardized method of assessing for alcohol dependence and treating alcohol alcohol dependence and treating alcohol withdrawal.withdrawal.

CAGE assessments will be implemented CAGE assessments will be implemented on all acute care admissions, in the ED and on all acute care admissions, in the ED and on ASU units.on ASU units.

The Alcohol Withdrawal Protocol will be The Alcohol Withdrawal Protocol will be ordered by the physician if indicated. He ordered by the physician if indicated. He will choose either a lorazepam or librium will choose either a lorazepam or librium protocol.protocol.

Summary cont’dSummary cont’d

An alchol withdrawal Caremap An alchol withdrawal Caremap will be implemented on all will be implemented on all patients with a primary patients with a primary diagnosis of alcohol withdrawal.diagnosis of alcohol withdrawal.

Nurses will be trained on how to Nurses will be trained on how to administer CIWA-Ar scoring.administer CIWA-Ar scoring.