Alcohol withdrawal
Published on Nov 18, 2015
An overview of alcoholism and alcohol withdrawal treatment in the hospital setting, including a review of the GMAWS, a potentially more user-friendly evaluation tool as compared to the standard CIWA scale.
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PRESENTATION OUTLINE
GOALs
- review Alcohol Use Disorders
- review Alcohol Withdrawal Seizures and Delerium Tremens
- talk about the current way we do things and the problems
- talk about alternative methods
This slide deck was prepared as part of ER rounds Feb 25th, 2014 at North Bay Regional Health Centre
thislooksinfected@gmail.com
thislooksinfected@gmail.com
Photo by Great Beyond
disclosures
- I've never been paid to speak
- I have no investments in companies making alcohol
- I have no investments in companies treating alcoholism
- My CAGE is 0/4
- My FAST-AUDIT is 0
themes
- Know what we know. Know what we don't know.
- Dispel myths
- Dx before Tx
- Keep It Simple, Stupid
Photo by davecito
Anyone got a case to discuss?
what about:
84 yo guy
second admission in one month for getting up at night to fry food, unexplained LOC, 2nd/3rd deg burns to the legs from the fry pan and oil
day 2 of admission, goes NUTS during the night
code white
soft restraints and haldol
CIWA 22?
no other medical treatment
next AM, CIWA zero and lucid and normal to the family doc who knows him
Says he sees his 1-year-dead wife sometimes at night
Says (on direct questioning) that he sees her more if he drinks
What's the diagnosis
(TRICK ANSWER: WE DON'T KNOW YET)
84 yo guy
second admission in one month for getting up at night to fry food, unexplained LOC, 2nd/3rd deg burns to the legs from the fry pan and oil
day 2 of admission, goes NUTS during the night
code white
soft restraints and haldol
CIWA 22?
no other medical treatment
next AM, CIWA zero and lucid and normal to the family doc who knows him
Says he sees his 1-year-dead wife sometimes at night
Says (on direct questioning) that he sees her more if he drinks
What's the diagnosis
(TRICK ANSWER: WE DON'T KNOW YET)
Alcohol use disorders?
- Isn't that just "alcoholism"?
- What about binge drinkers? Problem drinkers?
- How do we diagnose "Alcohol Use Disorder"?
Photo by solofotones
Alcohol withdrawal seizures
- To get them, you need to DRINK and you need to STOP
- Often 24 to 48 hours after stopping
- Up to 10% of all withdrawal cases (high estimate)
- "All gas, no brakes" phenomenon
- Usually self-limiting
RR of Alcohol Withdrawal Seizures if left untreated
CIWA RR
8-15 2
15-20 3
20-25 6
25+ 8
RR = multiplier of rates of BADNESS, if you leave them untreated and unobserved
CIWA RR
8-15 2
15-20 3
20-25 6
25+ 8
RR = multiplier of rates of BADNESS, if you leave them untreated and unobserved
Delirium tremens
- Is not just a delirium. It's an AUTONOMIC EMERGENCY
- Up to 3% of all alcohol withdrawals
- 72 to 96 hours after last drink
- The TREATED mortality can be 5%. Yikes!
- So...that seems worth preventing and treating...
Photo by mohammadali
So...how to we treat it?
- Identification (and a high index of suspicion)
- Observation? Monitoring? Lab work?
- Benzos? Anticonvulsants?
- What scales? What drugs? Given how?
- Valium? Thiamine? Glucose? Loading dose? Tapers?
Photo by André Hofmeister
but...
are we doing it right?
Gobsat
You're soaking in it.
As it turns out, much of what we do in alcohol withdrawal management is just class D evidence.
http://www.youtube.com/watch?v=dzmTtusvjR4
http://www.youtube.com/watch?v=dzmTtusvjR4
WHO?
(WHO'S BOOZIN')
Diagnosing
- Alcohol Use Disorders are high prevalence
- ...and have high morbidity and mortality
- ...but PLEASE...Dx before Tx. Get the diagnosis RIGHT
Who are you worried might be an alcoholic?
- a concussion 60yo on ASA admitted for observation
- a 30yo groom who overdid it at his bachelor party?
- an IVDU cocaine and bupropion addicted 50yo?
- a 45yo paralegal admitted for #humerus?
- a 35yo depressed homeless man with cirrhosis?
Did you get them all correct?
Some of them are controversial and tricky!
The trick answer is: "I don't know. I would screen them all"
Some of them are controversial and tricky!
The trick answer is: "I don't know. I would screen them all"
The C.A.G.E. questions
- For LIFETIME problem alcohol use ("Have you EVER...")
- Relies on SUBJECTIVE patient report
- More appropriate for family medicine
- Difficult to administer in grumpy people. Judge-y
- May miss sudden changes and new problems
Have you ever got the feeling that the CAGE questionnaire is kind of...lame?
Have you ever tried it on a homeless guy?
On a teenager?
In front of a family member?
Sensitivity 90%
Specificity 77%
Have you ever tried it on a homeless guy?
On a teenager?
In front of a family member?
Sensitivity 90%
Specificity 77%
Photo by angeloangelo
The FAST-Audit test
- More appropriate in acute care medicine
- Uses OBJECTIVE numbers
- Addresses what's happening with alcohol CURRENTLY
- In the ER or in hospital, probably use AUDIT, not CAGE
- Whether you CAGE or AUDIT, the point is to use a scale
There are different versions of the AUDIT questionnaire
All are available in the public domain
They range in sensitivity at around the 94% for alcoholism but importantly, they screen even better (ie 99%) for those at risk for Alcohol Withdrawal Seizures...which is the outcome we're wanting to prevent.
Do not fool yourself into thinking you can just rely on clinical acumen to "eyeball" who the risky folks are
http://bestbets.org/bets/bet.php?id=2213
All are available in the public domain
They range in sensitivity at around the 94% for alcoholism but importantly, they screen even better (ie 99%) for those at risk for Alcohol Withdrawal Seizures...which is the outcome we're wanting to prevent.
Do not fool yourself into thinking you can just rely on clinical acumen to "eyeball" who the risky folks are
http://bestbets.org/bets/bet.php?id=2213
Photo by rarvesen
WHEN?
(or...do we just put everyone on valium and go off shift?)
right now, we use CIWA-Ar
- But...it was invented in 1975
- ...as a RESEARCH tool, not a clinical tool
- It has nine 7-point scales and a 4 point orientation
- It is well-validated...but a negative score is EIGHT???
- ...and is UGLY
GMAWS
Come on...git in mah BELLY!
http://www.nursingtimes.net/Journals/2012/07/05/j/z/h/PrInnov-alcohol-12062...
http://qjmed.oxfordjournals.org/content/105/7/649.abstract
It's the Glasgow Modified Alcohol Withdrawal Scale. Done in Scotland for a REASON...
http://www.worldlifeexpectancy.com/cause-of-death/alcohol/by-country/
http://qjmed.oxfordjournals.org/content/105/7/649.abstract
It's the Glasgow Modified Alcohol Withdrawal Scale. Done in Scotland for a REASON...
http://www.worldlifeexpectancy.com/cause-of-death/alcohol/by-country/
glasgow modified alcohol withdrawal scale
- Was validated in 2010
- Has 5 items with a mnemonic, all scored zero to two
- Is PREFERRED by nurses and correlates with outcomes
- A negative score is ZERO
- ...and it's not as ugly
Untitled Slide
WHAT?
(Do we just use valium like June Cleaver did?)
Here's some choices
- chlordiazepoxide, diazepam, lorazepam
- phenobarbitol, GHB
- alpha blockers, beta blockers
- carbamazepine, dilantin, gabapentin, anticonvulsants
- ...and, ALCOHOL
Photo by Key Foster
Why preprinted orders
(other than "We're lazy and it's night shift")
What is the purpose of a PPO?
To save time in a narrow role once diagnosis is established. It is a preprinted ORDER to save penstrokes, not a preprinted DIAGNOSIS
It is meant to be simple, easy to use and appropriate for a specific role, but shouldn’t contain too many decision points.
It is iterative. You don’t just fire and forget. Rather, you initiate the PPO and reevaluate
To save time in a narrow role once diagnosis is established. It is a preprinted ORDER to save penstrokes, not a preprinted DIAGNOSIS
It is meant to be simple, easy to use and appropriate for a specific role, but shouldn’t contain too many decision points.
It is iterative. You don’t just fire and forget. Rather, you initiate the PPO and reevaluate
Photo by Adalberto Gonzaga
K.i.s.s.
Keep it Simple, Stupid
My ideal p.p.o.
- Only contains what has been PROVEN to work...
- ...for ONE specific condition
- ...and has as few decision points as possible
- My example is cleaned up from JAMA 1997: 278
- CAMH, St. Mikes, KGH examples were poor
Photo by blentley
ENTRY CRITERIA
- Patient probably has an Alcohol Use Disorder
- Patient drank a lot and then stopped (or will stop)
- Patient can communicate
- Patient is not currently intoxicated (you can start later)
- DON'T USE PPOs on the wrong candidates!
Photo by Nina Matthews Photography
Loading doses make people worse
- give more drugs, cause more sedation
- increased length of stay
- increase rates of discharge prescription
- AND DON'T IMPROVE OUTCOMES!!!!
Photo by hitthatswitch
fixed dose regimes don't work
- Higher doses given
- More chance of respiratory depression
- More morbidity in the frail elderly or medically sick
- AND DON'T IMPROVE OUTCOMES!!!!
Photo by Ennev
Intravenous fluids don't help
- Length of Stay same (280 minutes in ER)
- blood alcohol content the same (not renal excretion)
- Cost MORE
Intravenous 0.9% sodium chloride therapy does not reduce length of stay of alcohol-intoxicated patients in the emergency department: A randomised controlled trial
Siegfried RS Perez1,2,*,
Gerben Keijzers1,2,3,
Michael Steele4,
Joshua Byrnes3,5 and
Paul A Scuffham3,5
Article first published online: 8 NOV 2013
DOI: 10.1111/1742-6723.12151
Siegfried RS Perez1,2,*,
Gerben Keijzers1,2,3,
Michael Steele4,
Joshua Byrnes3,5 and
Paul A Scuffham3,5
Article first published online: 8 NOV 2013
DOI: 10.1111/1742-6723.12151
Photo by hmerinomx
Bloodwork doesn't help
- http://bestbets.org/bets/bet.php?id=1521
- ETOH, AST, GGT, Chem1, MCV, CDT
- NONE correlate with progress in alcohol withdrawal
- Don't order tests unless they change your management
Sure. Some bloodwork will get ordered for medical reasons. But it should NOT appear on the PPO. It is an unnecessary expense for no benefit...unless the clinician is LOOKING for something instead of "fishing"
Photo by MikeWebkist
Thiamine doesn't work
- There are NO trials demonstrating benefit in all-comers
- Journal of Emergency Medicine. 42(4):488-94, 2012 Apr.
- Case reports in dedicated Wernicke's WARDS in the 1970s
- You don't need to delay giving sugar
- Bottom line: Dx before Tx. Do you REALLY think it's Wernicke's
Treating everyone with vitamin B1 because they might have Wernicke's is about as sensible as treating everyone with vitamin C because they might have scurvy
What do you think is more common? hypoglycemia or beri-beri? There's an unintended consequence of chasing zebras
What do you think is more common? hypoglycemia or beri-beri? There's an unintended consequence of chasing zebras
Photo by geishaboy500
What about outpatients?
- Once your CIWA
- ...very difficult to prove Rx's reduce bounce-backs
- diazepam and lorazepam have a street value
- gabapentin 900-1200mg/d x 4 days works as well or better
- reduces cravings, return to drinking and withdrawal symptoms
current street value of 10mg valium is approx $1-$2
Alcoholism: Clinical & Experimental Research. 33(9):1582-8, 2009 Sep
taper to about half the dose by day 4
Alcoholism: Clinical & Experimental Research. 33(9):1582-8, 2009 Sep
taper to about half the dose by day 4
Rx: gabapentin 300mg
- S = 1 PO QID DAY 1
- 1 PO TID DAY 2 AND 3
- 1 PO BID DAY 4
- M = (12) TWELVE
This is what I may switch over to for outpatient prescribing once withdrawal symptoms have nearly dissipated
Photo by somegeekintn
