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 MedicineUW School of Medicine and Public Health

Director of Hospital MedicineUW Health Partners Watertown Regional Medical Center

Rock ‘n Roll Santa

Learning Objectives

At the conclusion of this presentation, you will beable 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:

• 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 down-regulation 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 up-regulation 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 • 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

©2014 UpToDate®

The effective management of AWS begins with a high level of suspicion and early recognition.

CIWA Scale• Nausea and vomiting

• Tremor

• Paroxysmal sweats

• Anxiety

• Agitation

• Tactile disturbances

• Auditory disturbances

• Visual disturbances

• Headache

• 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

• 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

• Age > 40• Cardiac disease• Hemodynamic instability• Marked acid-base

disturbance• Severe electrolyte

disturbance• Respiratory insufficiency• GI pathology• Serious infection, trauma

• 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 Questionnaire1. 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, non-judgemental intervention and referral.

Questions???