1. TRAUMA CARE BEYOND THE ED
South Central Regional Trauma
Advisory Council Conference
December 4, 2014
Verona, Wisconsin

2. Recognition and Management of Alcohol Withdrawal Syndrome in the Trauma Patient
Thomas McGorey, MD
Clinical Assistant Professor of Medicine
UW School of Medicine and Public Health
Director of Hospital Medicine
UW Health Partners Watertown Regional Medical Center

3. Rock ‘n Roll Santa

4. Learning Objectives
At the conclusion of this presentation, you will be
able to:
explain the pathophysiology of Alcohol Withdrawal Syndrome (AWS)
review use of an effective screening instrument for identifying AWS (CIWA)
review the principles of management and pharmacologic treatment of AWS
discuss the value of screening for at-risk drinking and use of brief interventions in the ED

5. Alcohol Withdrawal Syndrome (AWS) in Trauma Patients
Scope of the problem:
30-50% of all trauma patients have ingested some type of intoxicant prior to injury
Symptoms of AWS can mimic those of sepsis, brain injury and other conditions causing delirium
There is a positive correlation between alcohol intoxication and SIRS in the setting of trauma
Unrecognized and untreated, AWS can be fatal

6. Pathophysiology of AWS
Chronic alcohol exposure results in alterations in a number of neurotransmitter systems in the brain:
GABA (gamma-aminobutyric acid)
NMDA (N-methyl-D aspartate)
Dopamine
Norepinephrine
Cortisol

7. GABA GABA is an inhibitory CNS neurotransmitter
GABA receptors contain a binding site for ethanol
Chronic ethanol exposure leads to a down-regulation of GABA receptors
Upon withdrawal of ethanol, reduced number of GABA receptors means less CNS inhibition
Less CNS inhibition = CNS excitation

8. NMDA
NMDA is an excitatory CNS neurotransmitter that mediates post-synaptic excitatory effects of glutamate
Approximately 40% of synapses in the brain are glutamatergic
Chronic exposure to ethanol leads to an up-regulation of NMDA receptors
More NMDA receptors = CNS excitation

9. Dopamine, norepinephrine and cortisol
Dopamine and norepinephrine are excitatory neurotransmitters
Alcohol withdrawal results in an increase in dopamine and norepinephrine transmission
Leads to sympathetic hyperactivity and increased cortisol secretion from the adrenal glands (“fight or flight” response)

10. …the net effect of AWS
AWS results from an increase in the activity of excitatory neurotransmitters and a functional decrease in inhibitory receptors, resulting in a general sympathetic overdrive, resulting in
Anxiety
Tachycardia
Hypertension
Hyperthermia
Diaphoresis
Tremors
Agitation
Hallucinations
Seizures

11. Stages of Alcohol Withdrawal
Syndrome
Clinical Findings
Onset After Last Drink
Minor withdrawal
Tremors, anxiety, headache, diaphoresis, nausea, palpitations, normal mentation
6 to 36 hours
Withdrawal seizures
Isolated seizure or brief flurry of generalized tonic-clonic seizures, brief post-ictal period
6 to 48 hours
Alcoholic hallucinosis
Visual, auditory and/or tactile hallucinations with intact orientation and normal vital signs
12 to 48 hours
Delirium tremens
Delirium, agitation, tachycardia, hypertension, hyperthermia, severe diaphoresis, altered mentation
48 to 96 hours
©2014 UpToDate®

12. The effective management of AWS begins with a high level of suspicion and early recognition.

13. CIWA Scale Nausea and vomiting Tremor Paroxysmal sweats Anxiety
Agitation
Tactile disturbances
Auditory disturbances
Visual disturbances
Headache
Orientation and clouding of sensorium
Sullivan JT, Sykora K, Schneidermann J, Naranjo CA and Sellers EM. Assessment of alcohol withdrawal: The Revised Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWA-R). British Journal of Addiction 84: , 1989.

15. CIWA Protocol If CIWA score < 8, continue monitoring
Repeat Q2H x2, then QS x 72Hr
If CIWA score > 8, medicate
Reassess Q1Hr or sooner and medicate if > 8
Continue hourly CIWA score until < 8 on 6 subsequent assessments
If CIWA > 12, consider ICU admission, 1:1

16. Management of Alcohol Withdrawal Syndrome
Supportive care
IV fluids
Nutrition (glucose, thiamine, folate, MVI)
Electrolyte supplementation (K, Mg, P)
Environment
Medications
Other

17. Medications for AWS Benzodiazepines Barbiturates
diazepam (Valium)
lorazepam (Ativan)
chlordiazepoxide (Librium)
Barbiturates
phenobarbital
dexmedetomidine (Precedex)
propofol (Diprivan)

18. Benzodiazepines
Diazepam is the drug of choice due to its longer half-life and smoother control
Loading dose (CIWA > 12): 20 mg IV Q1H x 3 doses
Alternative Loading: mg IV Q5-10 min until adequate sedation
Maintenance: 10 mg IV Q1H if CIWA > 8
HOLD if RR < 12, SBP < 90 or excessive sedation

19. Benzodiazepines (cont’d)
Lorazepam (or oxazepam) should be used in patients with advanced liver disease to prevent accumulation of metabolites
2 mg PO or IV Q1H for CIWA score 8-11
4 mg PO or IV Q1H for CIWA score > 12
6 mg PO or IV Q1H for CIWA score equal or greater than previous
HOLD if RR < 12, SBP < 90 or excessive sedation
Consider lorazepam infusion if symptoms not controlled by bolus dosing

20. Other Medications
Phenobarbital can be useful in patients with severe AWS or inadequate sedation with standard benzodiazepine dosing in an effort to prevent progression to DTs
mg IV Q min
Dexmedetomidine (Precedex) can be useful in patients with refractory DTs
Load with 1 μg/kg over 10 min
Infusion rate of μg/kg/hr
Propofol
Initiate infusion at mg/kg/min
Titrate by mg/kg/min Q 5 min until desired sedation maintained

21. Prophylaxis for AWS
For patients with high risk for AWS, consider prophylaxis with chlordiazepoxide
mg PO Q6H x 24Hr, then
25-50 mg PO Q6H x 48 Hr
may convert to therapeutic dosing with mg PO Q1H if withdrawal symptoms develop

22. ICU Admission Age > 40 Cardiac disease Hemodynamic instability
Marked acid-base disturbance
Severe electrolyte disturbance
Respiratory insufficiency
GI pathology
Serious infection, trauma
Severe hyperthermia
Rhabdomyolysis
Renal insufficiency
Severe hypovolemia
History of previous DTs or withdrawal seizures
Need for frequent or high-dose sedatives
Need for sedative infusion
AWS despite elevated BAL
Carlson, RW, Keske, B, Cortez, D, J Crit Illness 1998; 13:311

23. Injury Prevention: Screening and Brief Intervention
“Trauma centers can use the teachable moment generated by the injury to implement and effective prevention strategy, for example, alcohol counseling for problem drinking. Alcohol is such a significant associated factor and contributor to injury that it is vital that trauma centers have a mechanism to identify patients who are problem drinkers. Such mechanisms are essential in Level I and II trauma centers. In addition, Level I centers must have the capability to provide an intervention for patients identified as problem drinkers. These have been shown to reduce trauma recidivism by 50%.”
Resources for Optimal Care of the Injured Patient: 2006, the American College of Surgeons Committee on Trauma (COT).

24. Screening for At-risk Drinking Behavior
CAGE alcohol questionnaire
AUDIT-C questionnaire
CRAFFT questionnaire (for adolescents)
Binge Drinking Question
Blood Alcohol Level (BAL)

25. CAGE Questionnaire
C: Have you ever felt you should cut down on your drinking?
A: Have people annoyed you by criticizing your drinking?
G: Have you ever felt bad or guilty about your drinking?
E: Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (eye-opener)?
*Two or more affirmative responses indicate alcohol abuse.
JA Ewing “Detecting Alcoholism: The CAGE Questionnaire” JAMA 252: , 1984.

26. AUDIT-C Questionnaire
1. How often do you have a drink containing alcohol?
Never
0 points
Monthly or less
1 point
2-4 times per month
2 points
2-3 times per week
3 points
4 or more times per week
4 points
How many drinks containing alcohol do you have on a typical
day when you are drinking?
1 or 2
0 points
3 or 4
1 point
5 or 6
2 points
7 to 9
3 points
10 or more
4 points

27. AUDIT-C Questionnaire (cont’d)
How often do you have 6 or more alcohol-containing drinks on
one occasion?
Never
0 points
Less than monthly
1 point
Monthly
2 points
Weekly
3 points
Daily or almost daily
4 points
*Recommended screening thresholds: > 4 points for men, > 3 points for women
Bush K, Kivlahan DR, McDonnell MB, et al. The SUDIT Alcohol Consumption Questions (AUDIT-C) brief screening test for problem drinking. Arch Internal Med (3):

28. CRAFFT Questionnaire
Have you ever ridden in a car driven by someone (including yourself) who was high or had been using alcohol or drugs?
Do you ever use alcohol or drugs to relax, feel better about yourself or fit in?
Do you ever use alcohol or drugs while you are alone?
Do you ever forget things you did while using alcohol or drugs?
Do your family or friends ever tell you that you should cut down on your drinking or drug use?
Have you ever gotten into trouble while you were using alcohol or drugs?
*Two or more affirmative responses indicate a potential problem.
Knight JR, Sherritt L, Shrier LA, Harris SK, Chang G. Validity of the CRAFFT substance abuse screening test among adolescent clinic patients. Archives of Pediatrics & Adolescent (6) , 2002.

29. Binge Drinking Question
When was the last time you had more that 5 drinks (4 for women) in one day?
*A report of binge drinking within the past 3 months is considered a positive response.
Williams RH, Vinson DC. Validation of a single question screen for problem drinking. Journal of Family Practice. 50(4): , 2001.

30. Blood Alcohol Level (BAL)
Simple blood test to measure the weigh of alcohol in a unit volume of blood (typically measured in g/dL or mg/dL).
Legal limit for intoxication in all 50 states is 0.08 g/dL (80 mg/dL).
Intoxication accompanied by trauma is sufficient to conclude that drinking behavior is high-risk and related to the injury.
In order to calculate the BAL present at the time of injury, add 15 mg/dL for each hour that has elapsed between the time of injury and the time the blood sample is drawn.

31. 3-step Simple Intervention
Provide information/feedback
Discuss meaning of patient’s score on the screening questionnaire and/or BAL result
Explain how injury may result from alcohol
Address patient’s views on drinking
Assess patient’s perception about his/her drinking
Ask patient if he/she thinks drinking played a role in the injury
Ask patient if he/she feels the need to change drinking behavior
Provide advice and negotiation
Advise patient to cut down or stop drinking, offer referral to AA or professional counseling, if desired
Advise to avoid driving or other risky activity after drinking
Help patient set a goal and formulate a plan
Communicate concern and respect and avoid being sarcastic, judgmental or demeaning

32. Take-home Points
Alcohol or other intoxicant ingestion is associated with between 30-50% of traumatic injuries seen in the ER.
A high index of suspicion, careful history taking and use of an assessment tool (CIWA) will help identify patients at risk of AWS.
Drug of choice in AWS is benzodiazepine.
Recognize patients appropriate for ICU.
Screen for at-risk drinking behavior in all trauma patients and be prepared to offer brief, non-judgemental intervention and referral.

33. Questions???