Alcohol Withdrawal

Development of Alcohol Withdrawal Caremap at Houlton Regional Hospital 2009

1. Alcohol WithdrawalAlcohol Withdrawal
Screening and TreatmentScreening and Treatment

2. 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.

3. 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 treating alcohol withdrawal is
not standardized.not standardized.

4. 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.

5. 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.

6. 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:

7. 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?

8. 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

9. 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.

10. 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.

11. 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).

12. 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

13. 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.

14. 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.

15. 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

16. Characteristic Features of Characteristic Features of
DT’sDT’s
HallucinationsHallucinations
DiaphoresisDiaphoresis
AgitationAgitation
Low grade feverLow grade fever
TachycardiaTachycardia
HypertensionHypertension
DisorientationDisorientation

17. 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

18. 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.

19. 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.

20. 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.

21. 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 vomiting
1 mild nausea with no vomiting1 mild nausea with no vomiting
22
33
4 intermittent nausea with dry heaves4 intermittent nausea with dry heaves
55
66
7 constant nausea, frequent dry heaves 7 constant nausea, frequent dry heaves
and vomitingand vomiting

22. 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 none
1 very mild itching, pins and needles, burning or 1 very mild itching, pins and needles, burning or
numbnessnumbness
2 mild itching, pins and needles, burning or 2 mild itching, pins and needles, burning or
numbnessnumbness
3 moderate itching, pins and needles, burning or 3 moderate itching, pins and needles, burning or
numbnessnumbness
4 moderately severe hallucinations4 moderately severe hallucinations
5 severe hallucinations5 severe hallucinations
6 extremely severe hallucinations6 extremely severe hallucinations
7 continuous hallucinations7 continuous hallucinations

23. CIWA-ArCIWA-Ar
TREMORTREMOR
-- Arms extended and fingers spread apart. -- Arms extended and fingers spread apart.
Observation.Observation.
0 no tremor0 no tremor
1 not visible, but can be felt fingertip to 1 not visible, but can be felt fingertip to
fingertipfingertip
22
33
4 moderate, with patient's arms extended4 moderate, with patient's arms extended
55
66
7 severe, even with arms not extended7 severe, even with arms not extended

24. 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 present
1 very mild harshness or ability to frighten1 very mild harshness or ability to frighten
2 mild harshness or ability to frighten2 mild harshness or ability to frighten
3 moderate harshness or ability to frighten3 moderate harshness or ability to frighten
4 moderately severe hallucinations4 moderately severe hallucinations
5 severe hallucinations5 severe hallucinations
6 extremely severe hallucinations6 extremely severe hallucinations
7 continuous hallucinations7 continuous hallucinations

25. CIWA-ArCIWA-Ar
PAROXYSMAL SWEATSPAROXYSMAL SWEATS
-- Observation.-- Observation.
0 no sweat visible0 no sweat visible
1 barely perceptible sweating, palms moist1 barely perceptible sweating, palms moist
22
33
4 beads of sweat obvious on forehead4 beads of sweat obvious on forehead
55
66
7 drenching sweats7 drenching sweats

26. 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 present
1 very mild sensitivity1 very mild sensitivity
2 mild sensitivity2 mild sensitivity
3 moderate sensitivity3 moderate sensitivity
4 moderately severe hallucinations4 moderately severe hallucinations
5 severe hallucinations5 severe hallucinations
6 extremely severe hallucinations6 extremely severe hallucinations
7 continuous hallucinations 7 continuous hallucinations

27. CIWA-ArCIWA-Ar
ANXIETYANXIETY
-- Ask "Do you feel nervous?" Observation.-- Ask "Do you feel nervous?" Observation.
0 no anxiety, at ease0 no anxiety, at ease
1 mild anxious1 mild anxious
22
33
4 moderately anxious, or guarded, so 4 moderately anxious, or guarded, so
anxiety is inferredanxiety is inferred
55
66
7 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

28. 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 present
1 very mild1 very mild
2 mild2 mild
3 moderate3 moderate
4 moderately severe4 moderately severe
5 severe5 severe
6 very severe6 very severe
7 extremely severe7 extremely severe

29. CIWA-ArCIWA-Ar
AGITATIONAGITATION
-- Observation.-- Observation.
0 normal activity0 normal activity
1 somewhat more than normal activity1 somewhat more than normal activity
22
33
4 moderately fidgety and restless4 moderately fidgety and restless
55
66
7 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

30. 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 additions
1 cannot do serial additions or is uncertain 1 cannot do serial additions or is uncertain
about dateabout date
2 disoriented for date by no more than 2 2 disoriented for date by no more than 2
calendar dayscalendar days
3 disoriented for date by more than 2 3 disoriented for date by more than 2
calendar dayscalendar days
4 disoriented for place/or person4 disoriented for place/or person

31. 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.

32. 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.

33. 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 (_______) of patient’s last alcohol
consumption.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 Score
Less 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 11-13 points 2 mg IV, IM or PO (indicate route) every 60 min
prn 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

34. 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 pointsNoneNone
9-10 points9-10 points 25 mg PO every 60 min prn25 mg PO every 60 min prn
11-13 points11-13 points 50 mg PO every 60 50 mg PO every 60
min prnmin prn
14-16 points14-16 points 75 mg PO every 60 75 mg PO every 60
min prnmin prn
Greater than 16 pointsGreater than 16 points100 mg PO every 30 min prn100 mg PO every 30 min prn
And 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 if score is 9 or greater, medicate per protocol
and recheck score and reassess patient in 1 and recheck score and reassess patient in 1
hour.hour.

35. 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: ________________

36. 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.

37. 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.

38. 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.

39. 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.