Transcript Alcohol Withdrawal - South Central Regional Trauma Advisory

TRAUMA CARE
BEYOND THE ED
South Central Regional Trauma
Advisory Council Conference
December 4, 2014
Verona, Wisconsin
Recognition and Management of
Alcohol Withdrawal Syndrome
in the Trauma Patient
Thomas McGorey, MD
Clinical Assistant Professor of Medicine
UW School of Medicine and Public Health
Director of Hospital Medicine
UW Health Partners Watertown Regional Medical Center
Rock ‘n Roll Santa
Learning Objectives
At the conclusion of this presentation, you will be
able to:
- explain the pathophysiology of Alcohol
Withdrawal Syndrome (AWS)
- review use of an effective screening instrument
for identifying AWS (CIWA)
- review the principles of management and
pharmacologic treatment of AWS
- discuss the value of screening for at-risk drinking
and use of brief interventions in the ED
Alcohol Withdrawal Syndrome (AWS)
in Trauma Patients
• Scope of the problem:
• 30-50% of all trauma patients have ingested some
type of intoxicant prior to injury
• Symptoms of AWS can mimic those of sepsis,
brain injury and other conditions causing delirium
• There is a positive correlation between alcohol
intoxication and SIRS in the setting of trauma
• Unrecognized and untreated, AWS can be fatal
Pathophysiology of AWS
• Chronic alcohol exposure results in alterations
in a number of neurotransmitter systems in
the brain:
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GABA (gamma-aminobutyric acid)
NMDA (N-methyl-D aspartate)
Dopamine
Norepinephrine
Cortisol
GABA
• GABA is an inhibitory CNS neurotransmitter
• GABA receptors contain a binding site for
ethanol
• Chronic ethanol exposure leads to a downregulation of GABA receptors
• Upon withdrawal of ethanol, reduced number
of GABA receptors means less CNS inhibition
• Less CNS inhibition = CNS excitation
NMDA
• NMDA is an excitatory CNS neurotransmitter
that mediates post-synaptic excitatory effects
of glutamate
• Approximately 40% of synapses in the brain
are glutamatergic
• Chronic exposure to ethanol leads to an upregulation of NMDA receptors
• More NMDA receptors = CNS excitation
Dopamine, norepinephrine and
cortisol
• Dopamine and norepinephrine are excitatory
neurotransmitters
• Alcohol withdrawal results in an increase in
dopamine and norepinephrine transmission
• Leads to sympathetic hyperactivity and
increased cortisol secretion from the adrenal
glands (“fight or flight” response)
…the net effect of AWS
• AWS results from an increase in the activity of
excitatory neurotransmitters and a functional decrease
in inhibitory receptors, resulting in a general
sympathetic overdrive, resulting in
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Anxiety
Tachycardia
Hypertension
Hyperthermia
Diaphoresis
Tremors
Agitation
Hallucinations
Seizures
Stages of Alcohol Withdrawal
Syndrome
Clinical Findings
Onset After
Last Drink
Minor withdrawal
Tremors, anxiety, headache, diaphoresis,
nausea, palpitations, normal mentation
6 to 36 hours
Withdrawal
seizures
Isolated seizure or brief flurry of generalized
tonic-clonic seizures, brief post-ictal period
6 to 48 hours
Alcoholic
hallucinosis
Visual, auditory and/or tactile hallucinations
with intact orientation and normal vital signs
12 to 48 hours
Delirium tremens
Delirium, agitation, tachycardia, hypertension,
hyperthermia, severe diaphoresis, altered
mentation
48 to 96 hours
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The effective management of
AWS begins with a high level
of suspicion and early
recognition.
CIWA Scale
• Nausea and vomiting
• Tactile disturbances
• Tremor
• Auditory disturbances
• Paroxysmal sweats
• Visual disturbances
• Anxiety
• Headache
• Agitation
• Orientation and
clouding of sensorium
http://wiki.hl7.org/images/2/25/Alcohol-Withdrawal-Assessment-Scale.pdf
Sullivan JT, Sykora K, Schneidermann J, Naranjo CA and Sellers EM. Assessment
of alcohol withdrawal: The Revised Clinical Institute Withdrawal Assessment for
Alcohol Scale (CIWA-R). British Journal of Addiction 84:1353-1357, 1989.
CIWA Protocol
• If CIWA score < 8, continue monitoring
– Repeat Q2H x2, then QS x 72Hr
• If CIWA score > 8, medicate
– Reassess Q1Hr or sooner and medicate if > 8
– Continue hourly CIWA score until < 8 on 6
subsequent assessments
• If CIWA > 12, consider ICU admission, 1:1
Management of
Alcohol Withdrawal Syndrome
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Supportive care
IV fluids
Nutrition (glucose, thiamine, folate, MVI)
Electrolyte supplementation (K, Mg, P)
Environment
Medications
Other
Medications for AWS
• Benzodiazepines
– diazepam (Valium)
– lorazepam (Ativan)
– chlordiazepoxide (Librium)
• Barbiturates
– phenobarbital
• dexmedetomidine (Precedex)
• propofol (Diprivan)
Benzodiazepines
• Diazepam is the drug of choice due to its
longer half-life and smoother control
– Loading dose (CIWA > 12): 20 mg IV Q1H x 3 doses
– Alternative Loading: 5-10 mg IV Q5-10 min until adequate
sedation
– Maintenance: 10 mg IV Q1H if CIWA > 8
– HOLD if RR < 12, SBP < 90 or excessive sedation
Benzodiazepines (cont’d)
• Lorazepam (or oxazepam) should be used in
patients with advanced liver disease to prevent
accumulation of metabolites
– 2 mg PO or IV Q1H for CIWA score 8-11
– 4 mg PO or IV Q1H for CIWA score > 12
– 6 mg PO or IV Q1H for CIWA score equal or greater
than previous
– HOLD if RR < 12, SBP < 90 or excessive sedation
– Consider lorazepam infusion if symptoms not
controlled by bolus dosing
Other Medications
• Phenobarbital can be useful in patients with severe
AWS or inadequate sedation with standard
benzodiazepine dosing in an effort to prevent
progression to DTs
– 130 - 260 mg IV Q 15-20 min
• Dexmedetomidine (Precedex) can be useful in patients
with refractory DTs
– Load with 1 μg/kg over 10 min
– Infusion rate of 0.2 -1 μg/kg/hr
• Propofol
– Initiate infusion at 0.005 mg/kg/min
– Titrate by 0.005 mg/kg/min Q 5 min until desired sedation maintained
Prophylaxis for AWS
• For patients with high risk for AWS, consider
prophylaxis with chlordiazepoxide
– 25-100 mg PO Q6H x 24Hr, then
– 25-50 mg PO Q6H x 48 Hr
– may convert to therapeutic dosing with 25-50 mg
PO Q1H if withdrawal symptoms develop
ICU Admission
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Age > 40
Cardiac disease
Hemodynamic instability
Marked acid-base
disturbance
Severe electrolyte
disturbance
Respiratory insufficiency
GI pathology
Serious infection, trauma
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Severe hyperthermia
Rhabdomyolysis
Renal insufficiency
Severe hypovolemia
History of previous DTs or
withdrawal seizures
• Need for frequent or
high-dose sedatives
• Need for sedative infusion
• AWS despite elevated BAL
Carlson, RW, Keske, B, Cortez, D, J Crit Illness 1998; 13:311
Injury Prevention:
Screening and Brief Intervention
“Trauma centers can use the teachable moment
generated by the injury to implement and effective
prevention strategy, for example, alcohol counseling for
problem drinking. Alcohol is such a significant
associated factor and contributor to injury that it is
vital that trauma centers have a mechanism to identify
patients who are problem drinkers. Such mechanisms
are essential in Level I and II trauma centers. In
addition, Level I centers must have the capability to
provide an intervention for patients identified as
problem drinkers. These have been shown to reduce
trauma recidivism by 50%.”
Resources for Optimal Care of the Injured Patient: 2006, the American College of Surgeons Committee on Trauma (COT).
Screening for At-risk Drinking Behavior
• CAGE alcohol questionnaire
• AUDIT-C questionnaire
• CRAFFT questionnaire (for adolescents)
• Binge Drinking Question
• Blood Alcohol Level (BAL)
CAGE Questionnaire
• C: Have you ever felt you should cut down on your drinking?
• A: Have people annoyed you by criticizing your drinking?
• G: Have you ever felt bad or guilty about your drinking?
• E: Have you ever had a drink first thing in the morning to
steady your nerves or get rid of a hangover (eye-opener)?
*Two or more affirmative responses indicate alcohol abuse.
JA Ewing “Detecting Alcoholism: The CAGE Questionnaire” JAMA 252: 1905-1907, 1984.
AUDIT-C Questionnaire
1. How often do you have a drink containing alcohol?
Never
0 points
Monthly or less
1 point
2-4 times per month
2 points
2-3 times per week
3 points
4 or more times per week
4 points
2. How many drinks containing alcohol do you have on a typical
day when you are drinking?
1 or 2
0 points
3 or 4
1 point
5 or 6
2 points
7 to 9
3 points
10 or more
4 points
AUDIT-C Questionnaire (cont’d)
3. How often do you have 6 or more alcohol-containing drinks on
one occasion?
Never
0 points
Less than monthly
1 point
Monthly
2 points
Weekly
3 points
Daily or almost daily
4 points
*Recommended screening thresholds: > 4 points for men, > 3 points for women
Bush K, Kivlahan DR, McDonnell MB, et al. The SUDIT Alcohol Consumption Questions (AUDIT-C)
brief screening test for problem drinking. Arch Internal Med. 1983 (3): 1789-1795.
CRAFFT Questionnaire
• Have you ever ridden in a car driven by someone (including
yourself) who was high or had been using alcohol or drugs?
• Do you ever use alcohol or drugs to relax, feel better about yourself
or fit in?
• Do you ever use alcohol or drugs while you are alone?
• Do you ever forget things you did while using alcohol or drugs?
• Do your family or friends ever tell you that you should cut down on
your drinking or drug use?
• Have you ever gotten into trouble while you were using alcohol or
drugs?
*Two or more affirmative responses indicate a potential problem.
Knight JR, Sherritt L, Shrier LA, Harris SK, Chang G. Validity of the CRAFFT
substance abuse screening test among adolescent clinic patients.
Archives of Pediatrics & Adolescent. 156 (6) 607-614., 2002.
Binge Drinking Question
• When was the last time you had more that 5 drinks (4 for
women) in one day?
*A report of binge drinking within the past 3 months is
considered a positive response.
Williams RH, Vinson DC. Validation of a single question screen for
problem drinking. Journal of Family Practice. 50(4): 307-312, 2001.
Blood Alcohol Level (BAL)
• Simple blood test to measure the weigh of alcohol in a unit
volume of blood (typically measured in g/dL or mg/dL).
• Legal limit for intoxication in all 50 states is 0.08 g/dL (80
mg/dL).
• Intoxication accompanied by trauma is sufficient to conclude
that drinking behavior is high-risk and related to the injury.
• In order to calculate the BAL present at the time of injury, add
15 mg/dL for each hour that has elapsed between the time of
injury and the time the blood sample is drawn.
3-step Simple Intervention
• Provide information/feedback
– Discuss meaning of patient’s score on the screening questionnaire and/or
BAL result
– Explain how injury may result from alcohol
• Address patient’s views on drinking
– Assess patient’s perception about his/her drinking
– Ask patient if he/she thinks drinking played a role in the injury
– Ask patient if he/she feels the need to change drinking behavior
• Provide advice and negotiation
– Advise patient to cut down or stop drinking, offer referral to AA or
professional counseling, if desired
– Advise to avoid driving or other risky activity after drinking
– Help patient set a goal and formulate a plan
– Communicate concern and respect and avoid being sarcastic, judgmental
or demeaning
Take-home Points
• Alcohol or other intoxicant ingestion is associated
with between 30-50% of traumatic injuries seen
in the ER.
• A high index of suspicion, careful history taking
and use of an assessment tool (CIWA) will help
identify patients at risk of AWS.
• Drug of choice in AWS is benzodiazepine.
• Recognize patients appropriate for ICU.
• Screen for at-risk drinking behavior in all trauma
patients and be prepared to offer brief, nonjudgemental intervention and referral.
Questions???