grand rounds
TRANSCRIPT
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WHAT IS THE BEST WAY TO MANAGE ACUTE ALCOHOL WITHDRAWAL SYNDROME?
OLIVIA J. WARNER | THE COMMUNITY COLLEGE OF BALTIMORE COUNTY | MAY 2016
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PATIENT ASSESSMENT• IS THIS PATIENT AT RISK FOR ACUTE
ALCOHOL WITHDRAWAL SYNDROME?•CAGE TOOL
• SIMPLE, FAST, EASY, RELIABLE• A SCORE OF 2-4 = AT RISK FOR
ALCOHOL WITHDRAWAL• OBTAIN DETAILED ALCOHOL HISTORY
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CLINICAL INSTITUTE OF WITHDRAWAL ASSESSMENT OF ALCOHOL – CIWA-AR• ASSIGNS A NUMERIC VALUE TO THE PATIENT’S LEVEL
OF ALCOHOL WITHDRAWAL ~ 0 TO 67• BASED ON THE SEVERITY OF PHYSICAL AND
PSYCHOLOGICAL SYMPTOMS• ⬆ SCORE = ⬆ SEVERITY OF WITHDRAWAL• DETERMINES FREQUENCY OF PATIENT ASSESSMENT• ALLOWS CALCULATION OF SYMPTOM-TRIGGERED
BENZODIAZEPINE DOSAGE
• NAUSEA/VOMITING• TREMOR• PAROXYSMAL SWEATS• ANXIETY• AGITATION• TACTILE DISTURBANCES• AUDITORY DISTURBANCES• VISUAL DISTURBANCES• HEADACHES/FULLNESS IN HEAD• ORIENTATION/CLOUDING OF
SENSORIUM
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BENZODIAZEPENES• SYMPTOM-TRIGGERED DOSAGE
SIGNIFICANTLY DECREASES BOTH THE DURATION OF TREATMENT AND THE TOTAL BENZODIAZEPINE USAGE DURING ACUTE ALCOHOL WITHDRAWAL (“BENZODIAZEPINES ARE THE MAINSTAY,” 2014)
• BASED ON THE INDIVIDUAL PATIENT’S SCORE AND WHETHER OR NOT IT IS IMPROVING
• REQUIRES OBJECTIVE WITHDRAWAL ASSESSMENT SCALE
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DELIRIUM TREMENS• LIFE THREATENING FORM OF ALCOHOL WITHDRAWAL• SYMPTOMS CAN INCLUDE HALLUCINATIONS,
IRREGULAR HEARTBEAT AND TONIC-CLONIC SEIZURES• ADMINISTER HALOPERIDOL IN ORDER TO MANAGE
SYMPTOMS (NORTHWEST HOSPITAL, 2015)
• LOW PLATELET COUNT AND HIGH BLOOD LEVEL OF HOMOCYSTEINE ARE PREDICTORS OF DELIRIUM TREMENS; VITAMINS B12, B6, AND FOLIC ACID COULD PREVENT DELIRIUM TREMENS (KIM, KIM, BAE, PARK, & KIM, 2015)
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WARNICKE-KORSAKOFF SYNDROME• WARNICKE’S ENCEPHALOPATHY CAN CAUSE ATAXIA, NYSTAGMUS, ALTERED
MENTAL STATUS AND CAN PROGRESS TO A COMA OR DEATH• KORSAKOFF’S PSYCHOSIS CAUSES SEVERE BRAIN DAMAGE THAT CAN CAUSE
HALLUCINATIONS, SEVERE MEMORY LOSS AND THE INABILITY TO FORM NEW MEMORIES
• ALL PATIENTS WHO ARE EXPERIENCING ALCOHOL WITHDRAWAL SHOULD RECEIVE ORAL THIAMINE AND THOSE AT HIGH RISK FOR WARNICKE’S ENCEPHALOPATHY SHOULD RECEIVE THIAMINE PARENTALLY FOR THREE DAYS (“MANAGING ALCOHOL WITHDRAWAL,” 2012)
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MANAGEMENT OF ACUTE ALCOHOL WITHDRAWAL SYNDROME• EARLY INTERVENTION – CAGE TOOL• SYMPTOM-TRIGGERED DOSAGE OF
BENZODIAZEPINES• USE HALOPERIDOL TO MANAGE SYMPTOMS
OF DELIRIUM TREMENS• ADMINISTER THIAMINE TO PREVENT
WARNICKE-KORSAKOFF SYNDROME
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REFERENCESBenzodiazepines are the mainstay of treatment for acute alcohol withdrawal syndrome. (2014). Drugs & Therapy Perspectives, 30, 395-398. http://dx.doi.org/10.1007/s40267-014-0152-2
Kim, D. W., Kim, H. K., Bae, E.-K., Park, S.-H., & Kim, K. K. (2015). Clinical predictors for delirium tremens in patients with alcohol withdrawal seizures. American Journal of Emergency Medicine, 33, 701-704. http://dx.doi.org/10.1016/j.ajem.2015.02.030 Management of alcohol withdrawal. (2012). Retrieved May 10, 2016, from http://www.who.int/mental_health/mhgap/evidence/alcohol/q2/en/
Northwest Hospital. (2015) Acute alcohol withdrawal symptom management (nursing). (Policy Number A-2). Randallstown, MD.