Alcohol Withdrawal

Starting December 1, 2022 we CAN accept selected patients at risk for and with active Alcohol Withdrawal Syndrome in ED Observation.

ED Observation will expand services offered to patients who are at risk for or experiencing mild uncomplicated alcohol withdrawal in addition to another ED Observation appropriate diagnosis. As a general rule of thumb, the degree of alcohol withdrawal should be such that the provider would be comfortable treating and discharging the patient if it weren’t for the other indication for admission to the ED Observation service.


Exclusions:


  • Withdrawal seizures or hallucinations as part of this ED presentation. A remote prior history of such complications is not a hard exclusion but providers are encouraged to exercise caution in this setting.

  • SEWS greater than 3 after treatment in the main Emergency Department

  • Active clinical* intoxication.

  • BAL > 150 with active withdrawal symptoms


* an elevated blood alcohol level is not necessarily an exclusion if the patient is clinically sober.


Treatment in the main ED prior to admission for ED observation


For patients in the main ED who have a diagnosis appropriate for ED observation but either have alcohol withdrawal or are at risk for alcohol withdrawal, and who do not meet any of the above exclusion criteria, the patient should be treated - at the providers discretion - until the SEWS is less than 3 prior to going to the ED observation unit. Providers are encouraged to use long acting medications to treat any symptoms, such as phenobarbital, diazepam, clorazepate, chlordiazepoxide, or oral ethanol.


Alcohol Withdrawal Treatment Protocol in the ED Observation Unit


  • Initial SEWS on arrival to ED Observation unit

    • Initial Bolus of Phenobarbital based on Initial SEWS

      • For SEWS of 0 No Medication Indicated

      • Phenobarbital 260 mg IV one time for SEWS of 1 or 2

      • Phenobarbital 5 mg / kg IV one time for SEWS of 3-12

      • Phenobarbital 10 mg / kg IV one time for SEWS of 13 or greater

  • SEWS monitoring by nursing

    • IF Initial or last SEWS = 0, calculate SEWS Q4 hours

    • IF Initial or last SEWS = 1 or 2, calculate SEWS Q2 hours

    • IF Initial or last SEWS = 3-12, Calculate SEWS Q1 hours

    • IF Initial or last SEWS is 13 or greater, calculate SEWS Q30 minutes

  • IF Repeat SEWS > 0 initiate treatment algorithm below

      • phenobarbital 65 mg IV Q1 h for SEWS of 1 or 2

      • phenobarbital 130 mg IV Q1 h for SEWS of 3-12

      • phenobarbital 260 mg IV Q1 h for SEWS of 13 or greater, provider to be notified, consider admission

  • Patient is to be admitted if they meet any of the following criteria

    • SEWS of 13 or higher is calculated on any repeat calculation

    • Patient develops hallucinations, seizure or agitated behaviors

    • SEWS remains > 0 after 8 hours of the above algorithm

    • Patient reaches maximum dose of 20 mg / kg of phenobarbital and has SEWS > 0


Alcohol Withdrawal Prevention Protocol in the ED Observation Unit

For patients who are at risk for Alcohol withdrawal during their observation stay but have not yet developed any signs or symptoms of withdrawal


  • If the patient has no contraindication to oral ethanol (e.g. clinical intoxication, inappropriate behavior, hepatitis, pancreatitis etc), and is expected to continue drinking alcohol at time of discharge then patients may be ordered oral alcoholic beverages to prevent alcohol withdrawal.

      • Review drinking history with the patient

      • Order "Alcoholic Beverage Panel" in eSummit and choose type, dose and frequency of drink accordingly.

  • If a patient does not want to continue drinking alcohol after discharge, or has a contraindication as above consider using a long acting oral benzodiazepine such as Librium or Tranxene

      • Calculate SEWS on arrival to ED obs and Q4 hours

      • Initial Dose

        • For patients at high risk for withdrawal, consider ordering an initial dose of clorazepate 30 mg on arrival to ED Observation

        • For patients at low risk for withdrawal, initial dose can be deferred until symptoms are noted

      • Ongoing doses

        • Clorazepate 15-30 mg Q8 hours PRN for SEWS > 0

  • If a patient develops a SEWS of 3 or greater with above preventative treatment please transition to Alcohol Withdrawal Treatment Protocol above