Links:
The ASAM Clinical Practice Gudieline on Alcohol Withdrawal Management (PDF)
- Initial considerations:
- Level of care (CIWA > 25 and/or high risk features usually needs ICU)
- Have they had delirium tremens in the past?
| hx of DTs/bad withdrawal* | years of heavy use |
| severe medical illness | BAL > 200 at presentation |
| quick symptom onset after last drink | underlying neurocog issues |
| head trauma | older age |
- High dose thiamine?
- Thiamine for treatment of Wernicke’s. Thiamine is cheap and very low risk. The threshold to decide to initiate therapy should be low. Give high dose thiamine (500mg IV Q8h x 3 days, then reassess)
- Confusion, hypothermia with hypotension, decreased consciousness, ataxia, nystagmus
- **stop high dose thiamine if symptoms completely resolve
- which benzo? do you need dexmedetomidine?
- Benzodiazepines – necessary to prevent seizures, must be used even if using dexmedetomidine
- Make PRN benzodiazepines available and notify nursing to contact you if given
- Assess patient Q4 hours initially and adjust doses as needed
- Hepatically metabolized – if liver dysfunction, utilize short acting benzos (lorazepam) to avoid stacking and unexpected over sedation/respiratory compromise
- Thiamine for treatment of Wernicke’s. Thiamine is cheap and very low risk. The threshold to decide to initiate therapy should be low. Give high dose thiamine (500mg IV Q8h x 3 days, then reassess)
Sample med regimens based on CIWA, physician should be notified of all medication administration
It is VERY important that one not confuse mild withdrawal for a patient faking the need for IV benzodiazepines. Also, using a CIWA protocol often lends towards administration of unneeded medication administration. Consider addition of haloperidol for agitation without sympathomimetic signs and symptoms.
CIWA < 8
– lorazepam 2mg PO or IV Q4 hours PRN for CIWA > 15
CIWA 8-15
– lorazepam 2mg PO or IV Q4 hours PRN for CIWA > 15 (low risk)
– diazepam 5mg Q8 hours with lorazepam PRN (with high risk features)
– chlordiazepoxide 10 q8 with lorazepam PRN (with high risk features)
CIWA 16-24
– diazepam 5 q8 or chlordiazepoxide 10 q 8 + prn lorazepam (lower risk)
– diazepam 10 q6-8 or chlordiazepoxide 25 q6-8 with PRN lorazepam
CIWA > 25
– diazepam 10 q6-8 or l chlordiazepoxide 25 q6-8 with PRN lorazepam (lower risk)
– diazepam 10-20mg PO/IV now until lightly sedated (can repeat dose) and then scheduled (lorazepam 10 q6-8) + PRN lorazepam