Alcohol Withdrawal in the ED
Clinical Institute Withdrawal Assessment-Alcohol revised (CIWA-Ar)
More than just an uncomfortable condition, alcohol withdrawal is potentially dangerous; improperly treated patients commonly develop seizures, and some progress to delirium tremens which can be life threatening.
In order to effectively deal with alcohol withdrawal in the emergency department (ED), clinicians must be able to 1) confidently identify patients in alcohol withdrawal, 2) determine which patients require treatment (not all will), and 3) understand the pharmacology of the medications primarily used to treat alcohol withdrawal (benzodiazepines), and the correct way to administer them.
While simplistic in principle, in practice treating alcohol withdrawal is a difficult task. Patients in alcohol withdrawal often have complex psycho-social, behavioural and polysubstance abuse issues which make them challenging to deal with. Administered incorrectly, benzodiazepines result in excessive sedation, potentially causing respiratory depression, prolonged ED length of stay and hospital admission. Additionally, benzodiazepines are commonly sought for secondary gain (they are highly addictive and often diverted to the black market). Given the complexity of the condition, and its treatment, it is perhaps not surprising that patients in alcohol withdrawal spend up to three times longer in the ED than other patients with similar CTAS scores.
The best way to manage alcohol withdrawal is using a symptom guided approach, in which patients are administered large doses of benzodiazepine medications early on in their treatment when symptoms are most severe, with treatment discontinued once symptoms are manageable. This results in shorter times to symptom resolution and lower overall doses of benzodiazepines administered with no increase in adverse outcomes compared to ad hoc or fixed dose treatment. The Clinical Institute Withdrawal Assessment-Alcohol revised (CIWA-Ar) is the most commonly used clinically validated tool for assessing alcohol withdrawal severity. Though it is the gold-standard, the CIWA-Ar is complex to administer (half the domains are subjective and difficult to quantify), and requires significant experience to reliably use. Among the domains assessed by the CIWA-Ar, tremor is the most objective and reliable indicator of withdrawal severity, yet still, the ability of clinicians to reliably quantify tremor is highly dependent on experience.
The assessment and management of alcohol withdrawal is not routinely taught to either physicians or nurses. Researchers at SREMI are in the process of developing and evaluating educational resources which will teach clinicians how to properly administer the CIWA-Ar, and to use this information to apply a symptom guided approach to the management of alcohol withdrawal. Our program uses e-learning modules and high fidelity simulation, and is centered on the use of an iOS app which calculates the CIWA-Ar and uses the accelerometer in the iPhone to objectively quantify tremor. The tremor assessment tool has been validated prospectively, and performs much better than standard clinical assessment. We anticipate that these resources will be effective, easily disseminated, and widely impact and improve the care of patients with alcohol withdrawal.