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33 Cards in this Set
- Front
- Back
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What is considered heavy alcohol users (at risk)?
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> 4 drinks/day in women
> 5 drinks/day in men |
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What is the incidence in cost and number of patients with AWS?
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Incidence of hospitalized patients with AWS is projected to be 2 billion/year with at least 500,000 of those requiring pharmacological treatment
AWS is underdiagnosed and often undertreated |
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Which neurotransmitters are associated with Alcohol use?
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GABA - inhibitory Glutamate - Action Brain activity has a balance between the two neurotransmitters.
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Risk Assessment for AWS
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Patient History is KEY
CAGE Questionnaire Have you ever tried to Cut down on your drinking? Do you ever get Annoyed by friends or family saying you drink too much? Do you ever feel Guilty about drinking? Do you ever feel the need for an Eye opener drink first thing in the morning? |
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How many questions in the CAGE questionnaire if answered "yes" would require the patient be monitored for AWS?
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Two questions.
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What are the clinical manifestations of AWS?
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Minor Symptoms
Major Symptoms Delirium Tremens |
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Minor Symptoms (Autonomic hyperactivity) - tremulousness (6-8 h)
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Occur anywhere from 6-24 hours after last drink
Insomnia Tremors Anxiety GI upset Headache Diaphoresis Palpitations Anorexia |
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Major Symptoms (Hallucination) 10-30 hr
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Occur anywhere from 24-72 hours after last drink
Hallucinations Able to maintain clear sensorium Seizures Occur in up to 10% of patients suffering from AWS Single, short, generalized tonic-clonic seizures Can recur successively but rarely progress to status-epilepticus |
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Define delirium tremens (DT).
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Typically occurs 48-72 hours from last drink
Considered the end point of AWS = medical emergency Occurs in up to 5% of patients with AWS Confusion, Disorientation Severe autonomic activity Hallucinations – inability to maintain clear sensorium Severe anxiety Can last up to 5 days Mortality used to be as high as 20% but more recently with appropriate detection and preventative treatment, it is around 1% |
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True or false: Delirium tremens is considered a medical emergency?
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True
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What's difference between the hallucinations of DT versus major symptoms?
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In DT, the patient has the inability to maintain clear sensorium.
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How long can DT last?
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Up to 5 days
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Risk Factors for DT
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History of previous DT
Longer history of sustained drinking Age > 30 Concurrent comorbidities Withdrawal symptoms even in the presence of elevated blood alcohol level |
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What is Kindling?
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Repeat episodes of AWS and alcohol detoxification lead to increased severity of alcohol withdrawal symptoms
Leads to permanent alterations in the GABA receptors Leads to increasingly gross neurohormonal imbalances and therefore more severe withdrawal symptoms |
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Lab Findings
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Elevated AST/ALT
Increased MCV (mean corpuscular volume) Hypomagnesaemia Hypokalemia Hypoalbuminemia – due to malnutrition |
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Differential Diagnosis
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CVA
Meningitis Head injury Drug overdose Electrolyte imbalance or other metabolic disturbance |
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Consider higher level of care (ICU)….
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CIWA > 12-15 for two consecutive assessments or initial CIWA > 20
HR > 100-130 bpm SBP > 175-200 mmHg Hyperthermia due to AWS (Temp > 38.5 C) Signs of over sedation (respiratory depression, hypotension, difficulty arousing the patient) Patient progressing to DT |
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What does CIWA-Ar stand for?
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Clinical Institute Withdrawal Assessment - Alcohol (revised)
Most widely used and well validated tool to predict risk for AWS based on patient symptoms |
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CIWA-Ar
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Maximum score = 30
Higher score = greater risk for AWS If initial score > 20, HIGH risk for seizure/DT – may need frequent monitoring such as every 15-60 minutes If initial score > 12-20, monitor every 2 hours If initial score < 12-15, monitor every 4 hours Once score < 8 for at least 24 hours, monitoring may be discontinued Directs nurse how much and when to administer medication for AWS Still need to treat the patient and not just the number |
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What are the two school of thoughts on when to administer medications for AWS?
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Symptom-triggered vs. Fixed-Dose therapy
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True or false: The fixed-dose therapy is the preferred method for medicating AWS?
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False - the symptom-triggered is the best method.
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Which class is the drug of choice for AWS?
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Benzodiazepines
Potentiate GABA to prevent seizure and prevent progression to DT Help with patient comfort and anxiety Lorazepam (Ativan) Diazepam (Valium) Chlordiazepoxide (Librium) |
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Why is Lorazepam usually the drug of choice when picking a Benzodiazepine?
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Available in IV/IM/PO/SL
Essentially non-metabolized so safe to use in patient with cirrhosis Shorter half life than diazepam but longer anti-seizure effect |
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What is the goal in AWS?
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Seizure and DT prevention.
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Select all the drugs used in AWS treatment:
Ativan Lithium Valium APAP |
Ativan and Valium. Not lithium - it should be librium.
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Diazepam
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Available IV/PO – IM absorption is erratic
Extensively metabolized by the liver Fast onset but longer half life than lorazepam |
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Chlordiazepoxide
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Available PO only
Fast onset but Long half life – potential for accumulation but can make for smoother withdrawal period Several metabolites |
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Benzodiazepines cont…
Different hospital protocols may vary widely and dosing is very dependent on individual patients |
Lorazepam
1-10mg Q1-6 hours PRN symptoms Diazepam 5-20mg Q 2-6 hours PRN symptoms Chlordiazepoxide 25-100mg Q2-6 hours PRN symptoms |
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Non-benzodiazepine Therapy
None have strong evidence to support their use in AWS and Benzodiazepines still remain standard of care but several small trials have been done with mixed results: |
Carbamazepine, Gabapentin, Valproic Acid - anticonvulsant
Baclofen – selective agonist of GABAB receptor Clonidine – central acting alpha-2 agonist GHB – weak GABAB agonist, converted to GABA in the body Haloperidol or other Antipsychotics Does not control the underlying pathophysiology related to seizure progression and can actually lower the seizure threshold Can be helpful adjunct to benzos to control hallucinations/agitation without worsening confusion. |
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Ethanol???
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Was used prior to benzodiazepines becoming standard of care
Given via IV infusion or just PO Theoretically allowed for faster discharge from the hospital since it negated the need for detoxification Disadvantages – very hard to titrate, short half life, can lower seizure threshold Behavioral concern that using ethanol inpatient appears to condone continued drinking |
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AWS vs Outpatient Treatment of Alcohol Dependence
Drugs used in the outpatient treatment of alcohol dependence are NOT used in the acute setting of AWS |
Disulfiram Acamprosate Naltrexone These drugs are used for maintenance of alcohol abstinence AFTER appropriate alcohol detoxification They are directed at reducing cravings for alcohol and do nothing to help stabilize the hyperexcitable state of the brain during AWS. |
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Supportive Care
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IVF
Crystalloid Fluids – usually NS or D5W/NS Aggressive rehydration usually needed at first Thiamine Prevention of Wernikes encephalopathy Essential for glycolysis and in the synthesis of Ach and GABA Glycolysis consumes thiamine, and since most alcoholics are at risk for hypoglycemia, thiamine should be given prior to any dextrose Folic Acid MVI “Banana Bag” – IV MVI, Thiamine, Folic Acid in isotonic fluid (NS or D5W/NS) Treat electrolyte disorders Hypomagnesemia Hypokalemia Hypophosphatemia |
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What drug should be given before infusing a patient with dextrose for the treatment of AWS?
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Thiamine - Glycolysis consumes thiamine, and since most alcoholics are at risk for hypoglycemia, thiamine should be given prior to any dextrose
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