ALCOHOL

WITHDRAWAL
CIWA-Ar
Clinical Institution of Withdrawal Assessment – Alcohol Revised
OVERVIEW
• What is Alcohol Withdrawal?
• How does it effect the brain and body?
• What can we do to manage it?
• What is CIWA-Ar?
• Review of the new CIWA-Ar Pre-printed Orders and
Assessment Scale
DANGERS OF ALCOHOL USE
• Most frequently abused substance in the world
• National Institute of Alcohol Abuse and Alcoholism report:
• 86% homicide
• 37% assaults
• 25-35% MVA
• … and unknown percentage in suicide
What is Alcohol Withdrawal
Syndrome?
• AWS is a potentially life-threatening condition that can occur
in people who have been drinking heavily for weeks, months,
or years and then either stop or significantly reduce their
alcohol consumption.
• AWS usually begins 6-8hrs after last drink and peaks around
72hrs.
• AWS can range from mild anxiety and shakiness to severe
complications, such as seizures and delirium tremens (DTs).
• The death rate from DTs is estimated to range from 1% to 5%.
• AWS can rapidly worsen if not caught, closely monitored and
treated.
Frequency in Hospital
• One survey reported that AWS occurs in:
• 8% of hospital admissions
• 16% post-surgical patients
• 31% trauma patients
NEUROTRANSMITTERS
• In the 1950’s they discovered that alcohol withdrawal was related to
two very critical receptors in the brain:
• NMDA
• GABA
• As well effects 5HT, NE, and others

Alcohol INHIBITES NMDA (excitatory) decreased brain excitability

+
Alcohol ENHANCES GABA (inhibitory)  decreased brain excitability
=
Desirable calming and anti-anxiolytic effects of EtOH
Effects on the Brain
• Heavy, prolonged drinking disrupts the brain’s neurotransmitters
• Chronic ingestion produces a tolerance, where by more and more
alcohol is needed to produce the same desirable effect
• Over time, the brain adjusts its own chemistry to compensate for
the effect of the alcohol.
• The brain does not know that alcohol ingestion is going to be
stopped, so continues to compensate by overproducing/over-
sensitize excitatory transmitters and block/de-sensitize inhibition
transmitters.
• When suddenly stopped, the brain goes into overdrive and is
EXTREMELY STIMULATED  Alcohol Withdrawal Syndrome
DSM-IV: AWS
A. Cessation of (or reduction in) heavy/prolonged alcohol use
B. Two (or more):
• Autonomic hyperactivity
• Increased hand tremor
• Insomnia
• Nausea or vomiting
• Transient visual, tactile, or auditory hallucinations or illusions
• Psychomotor agitation
• Anxiety
• Grand mal seizures
C. Above symptoms cause clinically significant distress
D. Symptoms are not due to general medical or mental health condition
FOUR STATES OF ALCOHOL
WITHDRAWAL
1. Autonomic Hyperactivity
2. Hallucinations
3. Neuronal Excitation
4. Delirium Tremens

• There is not necessarily a linear progression

1. Autonomic Hyperactivity:
• Clear sensorium (otherwise aware of what's going on)
• Increased HR, BP, Temp, breathing
• Tremulous
• Diaphoretic
• Anxiety
• Nausea
• Vomiting
• Increased catecholamine
• Start within 6-8hrs, peak within 24-48 hours
2. Hallucinations
• Sensitivity to lights, sounds, touch
• Most common = VISUAL
• Also common is the feeling of bugs (formication, tactile)
• May last up to 6 days
3. Neuronal Excitation
• Seizures
• Single, short, generalized
• Tonic-clonic
• Up to 10% of patients
• **Status epilepticus is NOT caused by alcohol withdrawal
4. Delirium Tremens
• Delirium with TREMOR
• Autonomic hyperactivity
• Hallucinations
• Electrolyte abnormalities
• Profoundly Dehydration
• Hemodynamic instability
• Mortality up to 15%
• Cardio/respiratory collapse
Diagnosis of Exclusion
**Must have recently stopped or significantly reduced your
alcohol consumption

• Other etiologies
• Sleep deprivation
• History of anesthesia
• Hypoxia
• Hypercapnia
• Traumatic brain injury
• Sepsis
• Sever anxiety
• Psychotic disorder
PREDICTING AWS
• History of withdrawal (personal or family)
• Strongest predictor
• Genetic component to susceptibility of AWS
• Not just delirium tremens
• CAGE Questionnaire
• An ETOH level is NOT necessary and can give a false
indicator
CAGE Questionnaire
• Cut Down
• Annoyed
• Guilty
• Eye Opener

** 2 or more positive responses are strongly associated with addiction

MANAGING ALCOHOL
WITHDRAWAL
• Principles of treatment
• Alleviate symptoms
• Prevent progression of symptoms
• Treat underlying comorbidities
• How do you do this?
• Supportive Care
• Source Control (lack of GABA suppression)
• Supplemental therapies
VITAMIN DEFICIENCY
• Most alcoholics exhibit vitamin deficiencies due to poor dietary habits and
changes in the digestive tract which impair the absorption of nutrients into the
bloodstream.
• Two dietary factors of particular importance are FOLIC ACID AND THIAMINE.
• Patients should receive a multivitamin containing folic acid each day.
• Thiamine deficiency can lead to Wernicke’s Encephalopathy (a type of delirium).
It is characterized by severe confusion, abnormal gait, and paralysis of certain eye
muscles.
• Wernicke’s Encephalopathy can progress to an irreversible dementia known as
Korsakoff Syndrome.
• Patients should receive Thiamine100 mg for a minimum of 3 days.
• Thiamine should always be administered before giving an alcoholic patient
glucose as an energy source to prevent precipitation of Wernicke syndrome by
depletion of thiamine reserves.
Source Control
• Source – loss of inhibition/sedation due to lack of EtOH
• Treatment = Replace the GABA activation (inhibition)
• How do we do that?
• Benzodiazepines
• GABA receptor agonist
• Alcohol replacement
• Gold standard for treatment
Which Benzo do I use?
• Very little evidence to support one benzo over another
• Pharmacokinetics
• Route of administration
• Onset of action
• Route of metabolism
• Length of half-life
• Diazepam
• Rapid onset
• Metabolized in liver
• Longer half-life
• Lorazepam
• Rapid onset if given IV, SL
• More preferred for patients with liver issues or elderly
• Shorter half-life
How do you know when to give it?
• This is more important than ‘what to give’

Fixed Dose Symptom Trigger

Dosing (CIWA-
Ar)
68hrs of tx 9hrs of tx
Librium 425mg Librium 100mg
Poor symptom control Better symptom control
How much Benzo is too much?
• Many patients are resistant to ‘normal’ benzo doses
• May need to increase dose 2-3x (maybe more)
• Ultimate goal is to get them through the withdrawal safety, not
necessarily remain abstinent
• Discussions regarding AA or community support can come
AFTER the withdrawal process. First goal is safety.
What is CIWA-Ar?
• The best known and most extensively studied AWS scale
• Well-documented reliability, reproducibility and validity
• Originally a 30 signs and symptoms assessment, this scale has been
carefully refined to a list of 10 signs and symptoms
• Each sign and symptom is scored independently
• The total score correlates to the severity of alcohol withdrawal
• Specific treatment management dependent on score (such as the
administration of benzodiazepines and frequency of assessments)
• Mild withdrawal is less than or equal to 15
• Moderate is 16 to 20
• Severe is greater than 20
• The maximum score is 67
CIWA-Ar
1. Nausea and Vomiting
2. Tremor
3. Paroxysmal Sweats
4. Anxiety
5. Agitation
6. Visual disturbances
7. Auditory disturbances
8. Tactile disturbances
9. Headache, fullness of head
10. Orientation, clouded sensorium
Behaviour Management
• Ignoring the symptoms or under medicating the symptoms will
only cause extreme behavioural disturbances!!
• Understand, appreciate and respect what the patient’s brain is
going through. Treat the withdrawal (benzos), and then
consider adjuncts
• Adjuncts are adjuncts, not monotherapy!
• B-blockers
• Neuroleptics
• Anti-convulsants
• Propofol
• All come with their own side effects and can mask the withdrawal
leading to under treatment with benzos
Review of New Pre-Printed Order Set
Questions?