Alcohol Withdrawal Recognition and Treatment

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1 Alcohol Withdrawal Recognition and Treatment Thomas Meyer BS EMS, MICP SREMSC Page 1

2 Purpose As EMTs a mantle of responsibility is placed upon you to ensure the safety and well-being of those in your charge This session is designed to be informative and preventative Page 2

3 Objectives To understand the process behind ETOH withdrawal Differentiate between abuse and dependence Recognize the symptoms of ETOH withdrawal and Delirium Tremens Consider appropriate treatment plans Page 3

4 Anatomy and Physiology There is one major and several minor neurotransmitters at work GABA Gamma AminoButyric Acid GABA A GABA B Dopamine Not the stuff we administer Page 4

5 Neurotransmitters As drinking increases, GABA A production in the body is reduced. ETOH floods the system with GABA A and the body no longer needs to make any. When drinking stops, you are neither supplying your body with GABA, nor is your body making GABA. Page 5

6 Withdrawal Defined Alcohol Withdrawal Syndrome: A set of symptoms seen when someone abruptly decreases or stops drinking LAME DEFINITION Page 6

7 Alcohol Withdrawal Syndrome Agitation Alcoholic hallucinosis Anorexia Anxiety and panic attacks Catatonia Confusion Delirium tremens Depersonalization Depression Derealization Diaphoresis Diarrhea Euphoria Fear Gastrointestinal upset Hallucinations Headache Hypertension Hyperthermia (fever) Insomnia Irritability Migraines Nausea and vomiting Palpitations Psychosis Rebound REM sleep Restlessness Seizures and death Tachycardia Tremors Weakness Page 7

8 Hang on a minute here There are actually two other concepts to be aware of Alcohol Abuse Alcohol Dependence Page 8

9 Alcohol Abuse Alcohol abuse is intentional overuse in cases of celebration, anxiety, despair, selfmedication, or ignorance, resulting in one or more of the following occurring within a 12-month period: Page 9

10 Alcohol Abuse Failure to fulfill major role obligations at work, school, or home Recurrent drinking in physically hazardous situations Recurrent alcohol-related legal problems Continued alcohol use despite having persistent or recurrent social and/or interpersonal problems caused or exacerbated by the effects of alcohol. Page 10

11 Alcohol Dependence Alcohol dependence is characterized by impaired control over alcohol use during intoxication and/or inability to abstain from drinking ("broken promises") as evidenced by: Page 11

12 Alcohol Dependence The need for markedly increased amounts of alcohol to achieve intoxication or desired effect, or markedly diminished effect with continued use of the same amount of alcohol (tolerance) Characteristic alcohol withdrawal syndrome with onset less than 24 hours after last "dose" of alcohol (tremors, sweats, nausea, anxiety, sleep disturbance, hallucinations, seizures) Page 12

13 Alcohol Dependence Persistent desire to drink, one or more unsuccessful efforts to cut down on drinking, and/or drinking in larger amounts than intended Giving up important social, occupational, and/or recreational activities because of drinking Spending a great deal of time in activities necessary to obtain alcohol or needing to drink to recover from the effects of alcohol Page 13

14 Alcohol Dependence Continued drinking despite knowledge of having persistent or recurring physical or psychological problem likely to be caused or exacerbated by alcohol use. Page 14

15 Alcohol Withdrawal Syndrome Agitation Alcoholic hallucinosis Anorexia Anxiety and panic attacks Catatonia Confusion Delirium tremens Depersonalization Depression Derealization Diaphoresis Diarrhea Euphoria Fear Gastrointestinal upset Hallucinations Headache Hypertension Hyperthermia (fever) Insomnia Irritability Migraines Nausea and vomiting Palpitations Psychosis Rebound REM sleep Restlessness Seizures and death Tachycardia Tremors Weakness Page 15

16 Symptoms of Alcohol Withdrawal Hours after last drink Symptoms of Withdrawal Peak Duration 6-12 hrs Tremors, N/V, anxiety, agitation tachycardia, HTN, insomnia, fever 6-48 hrs Seizures hrs Hallucinations hrs 48hrs 3-5 days Delirium tremens 2-5 days Page 16

17 Assessment CAGE Old School : Have you ever felt you should cut down on your drinking? Have people annoyed you by criticizing your drinking? Have you ever felt bad or guilty about drinking? Have you ever had a drink first thing in the morning to steady your nerves (eye-opener)? Page 17

18 Assessment Very, very subjective Now we use CIWA Clinical Institute Withdrawal Assessment CIWAr CIWA revised CIWAr M CIWA revised Modified Page 18

19 CIWAr Take a look at your CIWA form Complex Need training and practice Flexible? End up with a score Page 19

20 CIWA Shortcomings Requires screening to identify appropriate patients for use Requires trained staff Low scores may give false confidence High scores may be related to other disorders Difficult to use in non-communicative or mechanically-ventilated patients Page 20

21 CIWA Scoring 0 9 points, Mild Withdrawal points, Moderate Withdrawal 20 + points, Severe Withdrawal Page 21

22 Medications Chlordiazepoxide Librium Diazepam Valium Lorazepam Ativan Page 22

23 Treatment Two current models Fixed Schedule Regimen Symptom Triggered Page 23

24 Scheduled Dosing Efficiency? Amount given? Tendency for error? Ablation of Symptoms? Page 24

25 Fixed-schedule regimen Administer one of the following medications every 6 hours: Chlordiazepoxide, four doses of 50 mg, then eight doses of 25 mg Diazepam, four doses of 10 mg, then eight doses of 5 mg Lorazepam, four doses of 2 mg, then eight doses of 1 mg Page 25

26 Symptom Triggered Efficiency? Amount given? Tendency for error? Ablation of Symptoms? Page 26

27 Symptom Triggered Administer one of the following medications every hour when the CIWA-Ar score is at least 8 to 10 points: Chlordiazepoxide (Librium), 50 to 100 mg Diazepam (Valium), 10 to 20 mg Lorazepam (Ativan), 2 to 4 mg Page 27

28 Adjunctive Medications Haloperidol Haldol Atenolol Clonidine Phenytoin (Dilantin) Page 28

29 What you are getting into? Not here to run a rehab center Complex and difficult course Many more resources needed than you have Ongoing care is difficult Page 29

30 Levels of Evidence The revised Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scale is a validated 10-item assessment tool that can be used to quantify the severity of alcohol withdrawal syndrome, and to monitor and medicate patients going through withdrawal. Page 30

31 Levels of Evidence Symptom-triggered regimens have been shown to result in the administration of less total medication and to require a shorter duration of treatment. Page 31

32 Levels of Evidence In most patients with mild to moderate withdrawal symptoms, outpatient detoxification is safe and effective, and costs less than inpatient treatment. Page 32

33 Levels of Evidence Benzodiazepines have been shown to be safe and effective, particularly for preventing or treating seizures and delirium, and are the preferred agents for treating the symptoms of alcohol withdrawal syndrome. Page 33

34 Page 34

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