CIWA

Question 1

What drugs can people get for alcohol withdrawal?

Answer 1

Benzodiazepines

Barbiturates

Gabapentin

Adjuvant drugs

Question 2

what are adjuvant drugs

Answer 2

anticonvulsants, neuroleptic agents, sedative-hypnotics, antipsychotics, alpha agonists

Question 3

What is the MOA for benzos?

Answer 3

• increases GABA transmission and reduces CNS excitability, which decreases the risk for seizures and prevents the progression to DT

Question 4

What is the medications considered first line therapy for treatment of alcohol withdrawal?

Answer 4

• Benzos
• they halt the progression to delirium tremens
• Lam and Pam

Question 5

Which benzos are rapid acting?

Answer 5

• chlordiazepoxide

- diazepam (can be given to pts every 5-10min)

Question 6

What should you be aware of in pts conditions when giving chlordiazepoxide and diazepam?

Answer 6

These meds undergo hepatic metabolism.

The active metabolite may accumulate in the liver in pts with hepatic disease if the dose of the drug is not adjusted

Question 7

Which benzos are more appropriate for pts with liver dysfunction?

Answer 7

Alprzolam and lorazepam

Question 8

Which medications should you avoid in pts with alcohol withdrawal?

Answer 8

• Avoid phenytoin
• use benzos over antipsychotics
• avoid ETOH or opioids (abuse and addiction potential, psychomotor slowing, increased risk of falls, cog impairment)

Question 9

What additional drugs can be given in pts where benzos are contraindicated?

Answer 9

Phenobarbital

propofol

ketamine

dexmedetomidine

Question 10

How frequently are diazepam and lorazepam given?

Route and dosage preferred?

Answer 10

Diazepam given every 5-10 min
Lorazepam given every 15-20 min

Diazepam 10mg
Lorazepam 4mg

IV is preferred, but oral can be given in non-emergent situations

Question 11

What GABA (gamma-aminobutyric acid) have with alcohol withdrawal?

Answer 11

-reduce the production of GABA in the brain and throughout the body. When people do not have enough GABA to regulate their emotions, they often experience more mental health issues such as stress, depression, and paranoia

Chronic alcohol leads to downregulation of GABA receptors

During alcohol withdrawal, an acute reduction in alcohol use leads to decreased neurotransmission in GABA pathways and increased neurotransmission in NMDA pathways

Question 12

What happens as a result of this decreased neurotransmission of GABA pathways and increased neurotransmission in NMDA pathways?

Answer 12

The resulting neuronal hyperexcitability lowers the threshold for seizures

Upregulation of noradrenergic and dopaminergic pathways induces the autonomic hyperactivity and hallucinations associated w/ alcohol withdrawal

Question 13

What symptoms develop within several hours to a few days after cessation of or reduction in alcohol use

Answer 13

Autonomic hyperactivity (sweating or pulse rate greater than 100)

Increased hand tremor

Insomnia

N/V

transient visual, tactile hallucinations or illusions

psychomotor agitation

anxiety

grand mal seizures

*These symptoms are not d/t general medical conditions and are not better accounted for by another mental disorder, including intoxication or withdrawal from another substance.

Question 14

What is delirium Tremens?

Answer 14

Alcohol withdrawal delirium; characterized by confusion and an alteration in consciousness. Often accompanied by severe autonomic changes and hallucinations.

usually manifested within 2-5 days after the last drink

Question 15

What s/s might a pt with delirium tremens have?

Answer 15

fluctuating LOC

attention and cog deficits

hallucinations

confusion

HTN

Question 16

If delirium tremens is poorly managed, what should the nurse be aware of?

Answer 16

CV or resp collapse

arrhythmia

dehydration

electrolyte imbalance

MODs

*no treatment=high mortality rate

Question 17

What is the rationale to use various drugs in alcohol withdrawal?

Answer 17

• various drugs can manage severe withdrawal or delirium tremens
• also decreases the Length of stay and decreases admission and transfer to the ICU

Question 18

What are symptoms of alcohol withdrawal 24hrs after the last intake of alcohol? Are they mild?

Answer 18

Mild

tremor

Anxiety

diaphoresis

tachycardia

sleep disturbances

Question 19

What are progressive symptoms of alcohol withdrawal 12-24hrs after last intake?

Answer 19

fever

confusion

clouding of sensorium

hallucinations

seizures

*result of neuronal excitation

Question 20

What are more severe and feared complications of alcohol withdrawal and about how many days is it manifested after the last drink?

Answer 20

2-5 days after last drink

delirium tremens
- fluctuating LOC 
- attention and cog deficits
- hallucinations
- confusion
HTN

CV and resp collapse, arrhythmias, dehydration, electrolyte imbalance, MODs

Question 21

What is the key to managing alcohol withdrawal?

Answer 21

Early identification

obtain an ETOH hx!!

Question 22

Interventions and management:

Answer 22

• measurement of BG and appropriate administration of dextrose as well as naloxone can be life-saving and produce immediate changes in mentation thus revealing the etiology of the presentation
• fluid resuscitation in pts w/ alcohol use disoreder requires close monitoring of serum sodium to avoid beer poromania (the rapid provision of intravenous solute prompts sudden diuresis and hyponatremia)
• thiamine (vit B1) should be administered empirically for prevention of wernickes encephalopathy and korsakoffs psychosis

Question 23

What NMDA have with alcohol withdrawal?

Answer 23

• the upregulation of NMDA receptors

-