Alcohol Withdrawal in Acute Care In service by Denae Asel-Templin, OTS 3/18/16

Objectives Statistics What is alcohol withdrawal syndrome? Covenant’s Process Questions from PM&R

Statistics ___% of individuals in the US between 18-64 years meet the diagnostic criteria for alcohol dependence. In 2009, there were 4.6 million drug-related ED visits nationwide. ____ % of these involved alcohol use in combination with another drug Drug Abuse Warning Network (DAWN) does not account for alcohol use alone – this number is thought to be significantly higher than what is reported! 27% 2. 32% (over 600,000) Because DAWN does not account for ED visits involving alcohol use alone in adults, the actual number of ED visits involving alcohol among the general population is thought to be significantly higher than what is reported in DAWN.

Alcohol Withdrawal Syndrome Alcohol has a _______ effect on the CNS Alcohol withdrawal: hyperexcitability of the brain Signs: nausea, vomiting, sweating, shakiness, agitation, anxiety In its most severe form symptoms include severe confusion and visual hallucinations  Delirium Tremens Physiologically what is alcohol withdrawal? ____ = slowing or sedating We know that the use of alcohol has a slowing or sedating effect on the central nervous system, where the excitatory neurotransmitters are inhibited. once the depressant effect of alcohol is removed for heavy drinkers (aka when they stop drinking) every mechanism will overact within hours of the last drink, resulting in alcohol withdrawal syndrome

Covenant’s Process Alcohol Screening Brief Intervention Amount/Frequency Tool CAGE Tool Brief Intervention Clinical Institute Withdrawal Assessment Scale for Alcohol, Revised (CIWA-Ar) If the first two are found to be positive (alcohol screening/brief intervention) then CIWA-Ar is used Amount/Frequency screening tool basically just asks how many days per week does one drink and how many drinks per day on average do they drink. They multiply these numbers. If a patient’s score is more than 14 for men or 7 for women it’s thought the patient is at risk for developing alcohol related problems. CAGE is a 4 question screen (C: felt you should cut down on your drinking, A: been annoyed by criticism of your drinking, G: felt bad of guilty about your drinking, E: ever had a drink first thing in the morning). They are assigned 1 point for every question they respond “yes” to. If their score is 2 or more they may be at risk for developing alcohol related problems

CIWA-Ar Assessment Tool Date BP Heart Rate Nausea/vomiting? Tremors? Paroxysmal Sweats? Anxiety/Panic? Tactile Disturbances? Auditory Disturbances? Visual Disturbances? Headache/fullness Agitation? Orientation? CIWA-Ar Total Score Other than BP and HR all of these categories get a score between 0 and 7, 0 being the least sxs and 7 being the highest. Unfortunately online they don’t provide an outline of the scores I just know from asking the nurses. Once you assign a score and total them up there’s a “decision tree” that they follow for determining how to carry out this particular patient’s treatment.

Questions from PM&R What are in the banana bags nurses use? What is the legal limit? What are signs and symptoms at various blood alcohol concentration (BAC) levels? What are delirium tremens (DTs)? How long do symptoms last? Does confusion last long-term? What does ETOH stand for? Various essential nutrients – most commonly: folic acid, multivitamins, and thiamine All 50 states set .08% BAC as legal limit for driving under the influence (DUI) or driving while impaired (DWI) Levels are dependent on weight/tolerance. 0.10 – 0.12 BAC: euphoria (makes alcohol desirable), sense of coordination/balance significantly impaired, loud/overemotional stage 0.20 BAC: confused/disoriented, incoherent, risk of choking because gag reflex is impaired, pain sensation compromised, blackouts 0.40 BAC: death possible, ability to control breathing/HR so affected that it is likely to cease altogether. Need to call 911 Technical definition: severe form of alcohol withdrawal that involves sudden changes in one’s mental/nervous system. They commonly affect people with a history of alcoholism but are also seen in patients with head injury/infection. Signs & symptoms occur within 48-76 hours after the last drink most often however has been noted to occur 7-10 days after the last drink What I’ve found is that the length of signs and symptoms tend to differ based on the individual. However for most patients the signs and symptoms start to taper off after the first week but I also read that some don’t experience symptoms for a week. Very patient-based. Specifically looking at confusion I found that that peaks at 5 days- but again very patient-based. I also found a study about the complications of alcohol withdrawal and I thought that this was really interesting- when a person is experiencing alcohol withdrawal most individuals typically experience tremors and hallucinations first followed by seizures, which is followed by motor/autonomic overactivity & confusion and that confusion can take days to weeks to improve. ETOH is essentially an acronym for ethyl alcohol, also referred to as ethanol, ethyl alcohol is the type of alcohol found in alcoholic beverages.

Complications of Alcohol Withdrawal

References Covenant HeatlhCare – Patient Services. (n.d.). Alcohol screening & withdrawal management of an adult patient clinical practice guideline & procedure. Alcohol Withdrawal Clinical Practice. Drug Abuse Warning Network. (2011). DrugFacts: Drug-related hospital emergency room visits. National Institute on Drug Abuse. Retrieved from https://www.drugabuse.gov/publications/drugfacts/drug-related- hospital-emergency-room-visits Platzar, M. & Wilhelm, J. (n.d.). Care of the patient undergoing alcohol withdrawal. Cleveland Clinic. Retrieved from http://www.clevelandclinic.org/ddinursingsymp/pdfs/session1_1300APlatzarDDIPresentation1.pdf Trevisan, L., Boutros, N., Petrakis, I., & Krystal, J. (1998). Complications of alcohol withdrawal: Pathophysiological insights. Alcohol Health and Research World, 22(1). Retrieved from http://pubs.niaaa.nih.gov/publications/arh22-1/61-66.pdf