Alcohol Detox Procedure

Kind of difficult to follow but nevertheless interesting to those that are curious about what can occur in a hospital detox unit. The use of meds was helpful to me in understanding what alcoholics go through during a wd.

Date and time: Name: Age: Allergies:DOB:

1. Admit to: [ ] Acute Care [ ] Day Bed [ ] SCUnit [ ] Telemetry
2. Attending Dr: Younger
3. Admitting Dx: Acute Alcohol Intoxication
4. Contributing Dx:
5. Condition:[ ] Stable [ ] Fair [ ] Serious [ ] Critical
6. VS:qid with blood pressure sitting and standing.

Weight on admission and each AM.
7. Activity:Up with assistance.
8. Nursing:I/O Q shift.

Please evaluate the patient with the attached scale:

Addiction Research Foundation Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar)

Monitor the patient by administering the CIWA-Ar every four to eight hours until the score has been lower than 8 to 10 points for 24 hours, and perform additional assessments as needed for worsening symptoms of alcohol withdrawal.

In addition to the ordered routine every six-hour Librium, please administer an extra 50 mg of Librium up to every hour if the CIWA-Ar score is over eight points.9. Diet:Regular diet.10. IV:D5W/NS at 120 ml per hour. If the serum magnesium level is less than 1.5, then add 2 grams of Magnesium sulfate per liter of IV fluid X 2 liters, and then decrease to one gram per liter of IV fluid.11. Meds:Tylenol 1000 mg PO Q 4 hr prn pain.

Milk of Magnesia, 30 ml by mouth at bedtime as needed for constipation.

Ambien 5 mg, one tablet by mouth at bedtime and may repeat X 1 if needed for sleep.

Thiamine 100 mg by mouth daily X 3 days.

Folic acid 1 mg, one tablet by mouth daily.

Magnesium oxide 400 mg, one tablet by mouth 2 times a day (do not give if the patient is on IV magnesium sulfate).

Librium 50 mg, one tablet by mouth every 6 hours X 4 doses, then decrease to 25 mg q 6 hours po. X 3 doses, then 25 mg po every 8 hours X 3 doses, and then decrease to 25 mg po every 12 hours X 2 doses.

If the patient has visual/auditory hallucinations, whole body tremor, vomiting, diaphoresis, hypertension, agitation, fever, global confusion, or disorientation, then give the Librium 100 mg IM or po q 6 hours until the severe symptoms clear and restart the Librium tapering schedule.

Use Ativan Detoxification Schedule if the patient is > 60 years of age or has documented cirrhosis, esophageal varices, or has liver enzymes that are elevated more than two times the normal level.

Ativan 2 mg po q 6 hours X 4 doses, then 2 mg po q 8 hours X 3 doses, then 1 mg po q 6 hours x 4 doses, and then 1 mg po q 8 hours X 3 doses.

If symptoms of withdrawal occur with the Ativan protocol, give Ativan 4 mg po q 1-2 hours until the patient is sedated, then restart the tapering schedule.

Both Librium and Ativan can be given IV if the patient can or will not take the medication orally. The IM route can also be used if IV access is not present.

Alternative Tegretol for outpatient detoxification:

Carbamazepine (Tegretol) 200 mg 4 times on day 1,

200 mg 3 times on day 2,

200 mg 2 times on day 3,

and then 200 mg daily for 2 more days (5 days total).12. Other Meds:For nausea as needed use the following drugs:

Reglan 5 to 10 mg IV every 6 hours.

Zofran 4 mg IV every 6 hours.

The Reglan and the Zofran can be alternated every 3 hours to relieve nausea as needed.13. Labs:CBC, chem 8, calcium, blood alcohol level, protime, LFTs, phosphorous, magnesium, TSH, blood alcohol level, and urine drug screen (if not already done in the ER); repeat CBC, blood alcohol level, chem 8, calcium, LFTs, magnesium, and phosphorous on the AM after admission (with a protime if the 1st one was elevated).

EKG on admission;

Chest x-ray (PA and lateral) on admission.14. Other:Call MD if: altered mental status, T 101(F or higher, chest pain, pulse < 40 or >130, or the score on the Addiction Research Foundation Clinical Institute Withdrawal Assessment for Alcohol is greater than 20.15. Consultations:Please consult the Mental Health Center and have a substance abuse counselor evaluate the patient to see if he needs inpatient detoxification in a dedicated alcoholic detoxification center.16. H&P:Please type up the H&P.

________________________________________________Signature

Addiction Research Foundation Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar)

This scale is not copyrighted and may be used freely.

CIWA-Ar

Patient:__________________________ Date: ________________ Time: _______________.(24 hour clock, midnight = 00:00)

Pulse or heart rate, taken for one minute:_________________________ Blood pressure:______

NAUSEA AND VOMITING -- Ask "Do you feel sick to your stomach? Have you vomited?" Observation.0 no nausea and no vomiting1 mild nausea with no vomiting234 intermittent nausea with dry heaves567 constant nausea, frequent dry heaves and vomitingTACTILE DISTURBANCES -- Ask "Have you any itching, pins and needles sensations, any burning, any numbness, or do you feel bugs crawling on or under your skin?" Observation.0 none1 very mild itching, pins and needles, burning or numbness2 mild itching, pins and needles, burning or numbness3 moderate itching, pins and needles, burning ornumbness4 moderately severe hallucinations5 severe hallucinations6 extremely severe hallucinations7 continuous hallucinations

TREMOR -- Arms extended and fingers spread apart. Observation.0 no tremor1 not visible, but can be felt fingertip to fingertip234 moderate, with patient's arms extended567 severe, even with arms not extended

AUDITORY DISTURBANCES -- Ask "Are you more aware of sounds around you? Are they harsh? Do they frighten you? Are you hearing anything that is disturbing to you? Are you hearing things you know are not there?" Observation.0 not present1 very mild harshness or ability to frighten2 mild harshness or ability to frighten3 moderate harshness or ability to frighten4 moderately severe hallucinations5 severe hallucinations6 extremely severe hallucinations7 continuous hallucinations

PAROXYSMAL SWEATS -- Observation.0 no sweat visible1 barely perceptible sweating, palms moist234 beads of sweat obvious on forehead567 drenching sweats

VISUAL DISTURBANCES -- Ask "Does the light appear to be too bright? Is its color different? Does it hurt your eyes? Are you seeing anything that is disturbing to you? Are you seeing things you know are not there?" Observation.0 not present1 very mild sensitivity2 mild sensitivity3 moderate sensitivity4 moderately severe hallucinations5 severe hallucinations6 extremely severe hallucinations7 continuous hallucinations

ANXIETY -- Ask "Do you feel nervous?" Observation.0 no anxiety, at ease1 mild anxious234 moderately anxious, or guarded, so anxiety isinferred567 equivalent to acute panic states as seen in severedelirium or acute schizophrenic reactions

HEADACHE, FULLNESS IN HEAD -- Ask "Does your head feel different? Does it feel like there is a band around your head?" Do not rate for dizziness or lightheadedness. Otherwise, rate severity.0 not present1 very mild2 mild3 moderate4 moderately severe5 severe6 very severe7 extremely severe

AGITATION -- Observation.0 normal activity1 somewhat more than normal activity234 moderately fidgety and restless567 paces back and forth during most of the interview,or constantly thrashes about

ORIENTATION AND CLOUDING OF SENSORIUM --
Ask "What day is this?
Where are you?
Who am I?"

The CIWA-Ar is not copyrighted and may be reproduced freely. This assessment for monitoring withdrawal symptoms requires approximately 5 minutes to administer. The maximum score is 67 (see instrument). Patients scoring less than 10 do not usually need additional medication for withdrawal.

Sullivan, J.T.; Sykora, K.; Schneiderman, J.; Naranjo, C.A.; and Sellers, E.M. Assessment of alcohol withdrawal: The revised Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA-Ar). British Journal of Addiction 84:1353-1357, 1989.

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