Alcohol Withdrawal

• Alcohol Use Disorder (AUD) is prevalent in trauma patients.* Recognizing the risk and early signs of alcohol withdrawal syndrome (AWS) is critical in the SICU.

The spectrum of withdrawal symptoms ranges from mild to severe and life-threatening. The possible lethal sequela of AWS has resulted in the creation of AWS treatment protocols in most hospitals.

Symptom Spectrum

Minor Symptoms (Early AWS)

• Anxiety
• Headache
• Insomnia
• GI symptoms: nausea, cramping, pain

Advanced Symptoms (6–24 hours)

• Visual or auditory hallucinations
• Seizures

Severe Symptoms (Alcohol Withdrawal Delirium / Delirium Tremens)

• Alcohol Withdrawal Delirium (AWD) — a. k. a. delirium tremens
• Features: fever, tachycardia, agitation, diaphoresis, hallucinations, disorientation, hypertension

• Patients may develop AWD between 3–8 days after alcohol cessation.*

• Incidence:* 3–5% of all patients with AWS progress to AWD.

Although the incidence of AWD is relatively low, its lethal nature requires early identification and prevention for at-risk patients.

CIWA Assessment

The Clinical Institute Withdrawal Assessment for Alcohol (CIWA) is a validated tool that assesses the severity of withdrawal symptoms.

Key domains assessed by CIWA:

• Nausea / vomiting
• Tremor
• Paroxysmal sweats
• Anxiety
• Agitation
• Tactile disturbances
• Visual disturbances
• Auditory disturbances
• Headache
• Orientation / clouding of sensorium

CIWA-Ar (revised) scale: Score < 8 = mild; 8–15 = moderate; > 15 = severe

• Institution-specific CIWA order sets and protocols should be followed.* Refer to EPIC or your institutional order set.

Prevention

"An ounce of prevention is worth a pound of cure." — Benjamin Franklin, 1736

History & Physical — Key Questions for AUD Screening

• Last alcohol consumption
• Number of drinks per week
• History of binge consumption
• Previous hospitalizations for alcohol-related issues:
• Toxicity
• Pancreatitis
• Liver dysfunction / sequelae of cirrhosis
• Frequent ED visits with positive ETOH screens

Early Interventions for At-Risk Patients

Once a patient is determined to be at risk for AUD:

• Early initiation of CIWA protocols
• Thiamine supplementation (IV or IM) → Treats/prevents Wernicke's encephalopathy
• Multivitamin replacement
• Electrolyte correction
• Assessment for malnutrition secondary to AUD

Treatment

Historically, mainstay treatment was benzodiazepines and barbiturates.

These are being augmented by newer agents, including:

• Gamma-aminobutyric (GABAergic) agents
• Anti-epileptic drugs
• Alpha-2 adrenergic receptor agonists

For more information on novel approaches, see: "Novel Algorithms for the Prophylaxis and Management of Alcohol Withdrawal Syndromes — Beyond Benzodiazepines" by Maldonado (Journal of Hospital Medicine).

• Do NOT prescribe specific medication doses or protocols without attending guidance and your institution's current AWS order set.*

Important Notes

• This content is adapted from SurgCritCare. org
• Treatment protocols (benzodiazepine dosing, adjuncts, CIWA frequency) are institution-specific
• Always follow your institution's AWS order set in EPIC or your EHR
• Thiamine before glucose when Wernicke's is possible

• Adapted from SurgCritCare. org. Verify treatment protocols against current institutional AWS order set and attending guidance.*