Saving Lives By Strengthening Our Region’s Trauma Care System December 5, 2013 MANAGEMENT OF THE INJURED PATIENT IN ALCOHOL WITHDRAWAL

OBJECTIVES 1.Learn how to identify, assess and manage a patient in alcohol withdrawal. 2.Develop an understanding and use of evidence- based 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 Diagnostic Criteria Pathophysiology Manifestations / Signs and Symptoms Assessment – Assessment Tools Management – Pharmacological – Nursing Case Study / Review CIWA-Ar in practice…

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. FACTS / STATISTICS

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. DEFINITIONS

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 (symptoms usually resolve within 48 hours) Alcohlic hallucinosis: visual, auditory, or tactile hallucinations 24 to 48 hours (symptoms reported as early as two hours after cessation) Withdrawal seizures: generalizaed tonic- clonic seizures 48 to 72 hours (symptoms peak at five days) 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 non- confrontational 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 (Eye- opener)?

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: 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 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(lorazepam) RouteOnsetPeakDuration P.O.1 hr2 hr12-24 hr I.V.5 min60-90 min6-8 hr I.M min60-90 min6-8 hr Librium(chlordiazepodie hydrochloride) RouteOnsetPeakDuration P.O.Unknown1/2-4 hrUnknown Valium(diazepam) RouteOnsetPeakDuration P.O.30 min2 hr20-80 hr I.V.1-5 min min I.M.Unknown2 hrUnknown P.R.Unknown90 minUnknown

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 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 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 alcohol- related 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: U.C. San Diego Medical Center

ANN BUNNELL, MSN, APNP, PMHCNS-BS JENNY KLEINERT, BSN, RN-BC, PMHN QUESTIONS…

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