Alcohol Withdrawal in the YK Delta - Revision history

JenniferH at 08:58, 20 November 2020

2020-11-20T08:58:09Z

← Older revision		Revision as of 08:58, 20 November 2020
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	<br />		<br />
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			==Resources==
			*[[media:Alcohol_hangover_withdrawal.pdf\|Alcohol Hangover/Withdrawal YKHC Clinical Guideline]]
			*[[media:Intoxicated_ED_patient.pdf\|Intoxicated ED Patient YKHC Clinical Guideline]]
			*[[Phenobarbital for Alcohol Withdrawal]] by Dr. Andrew Swartz
			*[http://epibulletins.dhss.alaska.gov/Bulletin/DisplayClassificationBulletins/221 Alaska Department of Health and Social Services (ADHSS) Epidemiology Bulletin: Alcohol Consumption]

	==References==		==References==
	<references />		<references />

AndyS at 18:54, 23 September 2019

2019-09-23T18:54:07Z

← Older revision		Revision as of 18:54, 23 September 2019
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	:Travis Nelson, MD <br />		:Travis Nelson, MD <br />
	'''Reviewers'''		'''Reviewers'''
			:Tara Lathrop, MD (Emergency Department Service Chief)
	<br />		<br />
	<br />		<br />
	==References==		==References==
	<references />		<references />

AndyS at 18:31, 23 September 2019

2019-09-23T18:31:30Z

@@ Line 20: / Line 20: @@
 ;Etiology of vomiting
 :Alaska Natives  have a very high rate of both chronic gastritis and/or H. pylori infection, and binge drinking frequently exacerbates or unmasks this condition.  Yet nausea and vomiting are common symptoms of alcohol withdrawal in patients without any appreciable degree of gastritis.  To efficiently treat the nausea and vomiting, the astute clinician’s task is to assess whether the nausea and vomiting are mostly attributable to gastritis, withdrawal, or a combination.  The best indicator is the history.  If the patient is in withdrawal because they stopped drinking because of abdominal pain and vomiting, then gastritis is the likely etiology, and an anti-emetic and a GI cocktail are high yield.  But if the patient stopped drinking due to lack of access to alcohol and the vomiting subsequently started with the withdrawal symptoms, then withdrawal is the likely etiology of the vomiting, and GABA agonist treatment will likely fix the vomiting.  When the etiology is mixed, both treatments are indicated.
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@@ Line 34: / Line 50: @@
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+==Contributors==
 ==References==
 <references />

AndyS: /* Alcohol Withdrawal in Villages */

2019-09-22T17:13:27Z

Alcohol Withdrawal in Villages

← Older revision		Revision as of 17:13, 22 September 2019
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	==Alcohol Withdrawal in Villages==		==Alcohol Withdrawal in Villages==
	The following resources are available for AWS treatment in the villages:		The following resources are available for AWS treatment in the villages:
	::::# IM phenobarbital		::::# '''GABA agonist''': IM phenobarbital
	::::# ~~IV fluid~~		::::# '''Anti-emetic''': _
	::::# ~~...~~		::::# '''IV fluid''': NS and LR
	<br />		<br />
	<br />		<br />

	==References==		==References==
	<references />		<references />

AndyS at 06:27, 22 September 2019

2019-09-22T06:27:33Z

← Older revision		Revision as of 06:27, 22 September 2019
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	;Intoxicated or sick patients		;Intoxicated or sick patients
	:Patients suffering alcohol withdrawal do not fall asleep while waiting to be seen. Alcohol withdrawal is a state of autonomic hyper-activity and hyper-alertness. Consequently, most withdrawing patients have an ''inability'' to sleep. The patient who is drowsy or falling asleep is almost certainly intoxicated and pursuing some type of secondary gain (i.e. hangover prevention, a place to sleep, prescription medication abuse, etc.) or suffering from some other medical problem. The clinician should be alert to the co-existence of other medical problems which require treatment, but providing the desired secondary gain should be avoided.		:Patients suffering alcohol withdrawal ''do not fall asleep'' while waiting to be seen. Alcohol withdrawal is a state of autonomic hyper-activity and hyper-alertness. Consequently, most withdrawing patients have an ''inability'' to sleep. The patient who is drowsy or falling asleep is almost certainly intoxicated and pursuing some type of secondary gain (i.e. hangover prevention, a place to sleep, prescription medication abuse, etc.) or suffering from some other medical problem. The clinician should be alert to the co-existence of other medical problems which require treatment, but providing the desired secondary gain should be avoided.
	<br />		<br />
	;Reasons to treat		;Reasons to treat
	:Prevention of seizing is an inadequate clinical endpoint. If the pacing, tremulous patient is driving you and/or the staff crazy, then they are almost certainly doing the same to their housemates. The patient's access to a bed or couch to sleep on frequently depends upon adequate treatment of their withdrawal symptoms. If a patient is so irritating that everyone kicks them out, they will almost certainly bounce back to the ED. This alone is a reason to treat alcohol withdrawal. Patients who can sit still, keep down oral intake, and sleep are MUCH less likely to bounce back; and patients who ~~are~~ pacing, tremulous, and vomiting are almost guaranteed to bounce back.		:Prevention of seizing is an inadequate clinical endpoint. If the restless, pacing, tremulous patient is driving you and/or the staff crazy, then they are almost certainly doing the same to their housemates. The patient's access to a bed or couch to sleep on frequently depends upon adequate treatment of their withdrawal symptoms. If a patient is so irritating that everyone kicks them out, they will almost certainly bounce back to the ED. This alone is a reason to treat alcohol withdrawal. Patients who can sit still, keep down oral intake, and sleep are MUCH less likely to bounce back; and patients who leave restless, pacing, tremulous, and vomiting are almost guaranteed to bounce back.
	<br />		<br />
	;Etiology of vomiting		;Etiology of vomiting
	:Alaska Natives have a very high rate of both chronic gastritis and/or H. pylori infection, and binge drinking frequently exacerbates or unmasks this condition. Yet nausea and vomiting are common symptoms of alcohol withdrawal in patients without any appreciable degree of gastritis. To efficiently treat the nausea and vomiting, the astute clinician’s task is to assess whether the nausea and vomiting are mostly attributable to gastritis, withdrawal, or a combination. The best indicator is the history. If the patient is in withdrawal because they stopped drinking because of abdominal pain and vomiting, then gastritis is the likely etiology, and an anti-emetic and a GI cocktail are high yield. But if the patient stopped drinking due to lack of access to alcohol and the vomiting subsequently started with the withdrawal symptoms, then withdrawal is the likely etiology of the vomiting, and GABA agonist treatment will likely fix the vomiting. When the etiology is mixed, both ~~treatment regimens~~ are ~~required~~.		:Alaska Natives have a very high rate of both chronic gastritis and/or H. pylori infection, and binge drinking frequently exacerbates or unmasks this condition. Yet nausea and vomiting are common symptoms of alcohol withdrawal in patients without any appreciable degree of gastritis. To efficiently treat the nausea and vomiting, the astute clinician’s task is to assess whether the nausea and vomiting are mostly attributable to gastritis, withdrawal, or a combination. The best indicator is the history. If the patient is in withdrawal because they stopped drinking because of abdominal pain and vomiting, then gastritis is the likely etiology, and an anti-emetic and a GI cocktail are high yield. But if the patient stopped drinking due to lack of access to alcohol and the vomiting subsequently started with the withdrawal symptoms, then withdrawal is the likely etiology of the vomiting, and GABA agonist treatment will likely fix the vomiting. When the etiology is mixed, both treatments are indicated.
	<br />		<br />
	<br />		<br />

AndyS at 01:23, 22 September 2019

2019-09-22T01:23:30Z

← Older revision		Revision as of 01:23, 22 September 2019
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	==Treatment Principles and Pearls==		==Treatment Principles and Pearls==
	;Breath alcohol level		;Breath alcohol level
	:All patients complaining of alcohol withdrawal should have a breath alcohol level measured. This is truly the "fifth vital sign" in such patients. The presence of a measurable alcohol level does not rule-out withdrawal, but it does provide important information for ~~management during~~ this and/or future visits.		:All patients complaining of alcohol withdrawal should have a breath alcohol level measured. This is truly the "fifth vital sign" in such patients. The presence of a measurable alcohol level does not rule-out withdrawal, but it does provide potentially important information for managing this and/or future visits.
	<br />		<br />
	;Intoxicated or sick patients		;Intoxicated or sick patients

AndyS at 01:22, 22 September 2019

2019-09-22T01:22:09Z

← Older revision		Revision as of 01:22, 22 September 2019
Line 28:		Line 28:
	<br />		<br />
	==Alcohol Withdrawal in Villages==		==Alcohol Withdrawal in Villages==
			The following resources are available for AWS treatment in the villages:
			::::# IM phenobarbital
			::::# IV fluid
			::::# ...
	<br />		<br />
	<br />		<br />
	==References==		==References==
	<references />		<references />

AndyS at 19:06, 21 September 2019

2019-09-21T19:06:08Z

← Older revision		Revision as of 19:06, 21 September 2019
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	<br />		<br />
	<br />		<br />
	== ~~'''~~Treatment Principles and Pearls~~'''~~ ==		==Treatment Principles and Pearls==
	;Breath alcohol level		;Breath alcohol level
	:All patients complaining of alcohol withdrawal should have a breath alcohol level measured. This is truly the "fifth vital sign" in such patients. The presence of a measurable alcohol level does not rule-out withdrawal, but it does provide important information for management during this and/or future visits.		:All patients complaining of alcohol withdrawal should have a breath alcohol level measured. This is truly the "fifth vital sign" in such patients. The presence of a measurable alcohol level does not rule-out withdrawal, but it does provide important information for management during this and/or future visits.
Line 22:		Line 22:
	<br />		<br />
	<br />		<br />
	== ~~'''~~Phenobarbital~~'''~~ ==		==Phenobarbital==
	IV/IM phenobarbital is the preferred outpatient treatment of alcohol withdrawal at our facility.		IV/IM phenobarbital is the preferred outpatient treatment of alcohol withdrawal at our facility.
	See ''[[Phenobarbital for Alcohol Withdrawal]]'' for details.		See ''[[Phenobarbital for Alcohol Withdrawal]]'' for details.
	<br />		<br />
	<br />		<br />
	== ~~'''~~Alcohol Withdrawal in Villages~~'''~~ ==		==Alcohol Withdrawal in Villages==
	<br />		<br />
	<br />		<br />
	== ~~'''~~References~~'''~~ ==		==References==
	<references />		<references />

AndyS at 18:26, 21 September 2019

2019-09-21T18:26:41Z

← Older revision		Revision as of 18:26, 21 September 2019
Line 13:		Line 13:
	<br />		<br />
	;Intoxicated or sick patients		;Intoxicated or sick patients
	:Patients suffering alcohol withdrawal do not fall asleep while waiting to be seen. Alcohol withdrawal is a state of autonomic hyper-activity and hyper-alertness. Consequently, most withdrawing patients ~~present with~~ an inability to sleep. The patient who is drowsy or falling asleep is almost certainly intoxicated and pursuing some type of secondary gain (i.e. hangover prevention, a place to sleep, prescription medication abuse, etc.) or suffering from some other medical problem. The clinician should be alert to the co-existence of ~~true~~ medical problems which require treatment, but providing the desired secondary gain should be avoided.		:Patients suffering alcohol withdrawal do not fall asleep while waiting to be seen. Alcohol withdrawal is a state of autonomic hyper-activity and hyper-alertness. Consequently, most withdrawing patients have an ''inability'' to sleep. The patient who is drowsy or falling asleep is almost certainly intoxicated and pursuing some type of secondary gain (i.e. hangover prevention, a place to sleep, prescription medication abuse, etc.) or suffering from some other medical problem. The clinician should be alert to the co-existence of other medical problems which require treatment, but providing the desired secondary gain should be avoided.
	<br />		<br />
	;Reasons to treat		;Reasons to treat
Line 19:		Line 19:
	<br />		<br />
	;Etiology of vomiting		;Etiology of vomiting
	:Alaska Natives have a very high rate of both chronic gastritis and/or H. pylori infection, and binge drinking frequently exacerbates or unmasks this condition. Yet nausea and vomiting are a common ~~symptom~~ of alcohol withdrawal in patients without any appreciable degree of gastritis. To efficiently treat the nausea and vomiting, the astute clinician’s task is to assess whether the nausea and vomiting are mostly attributable to gastritis, withdrawal, or a combination. The best indicator is the history. If the patient is in withdrawal because they stopped drinking because of abdominal pain and vomiting, then gastritis is the likely etiology, and an anti-emetic and a GI cocktail are high yield. But if the patient stopped drinking due to lack of access to alcohol and the vomiting started the withdrawal symptoms, then withdrawal is the likely etiology of the vomiting, and GABA agonist treatment will likely fix the vomiting.		:Alaska Natives have a very high rate of both chronic gastritis and/or H. pylori infection, and binge drinking frequently exacerbates or unmasks this condition. Yet nausea and vomiting are common symptoms of alcohol withdrawal in patients without any appreciable degree of gastritis. To efficiently treat the nausea and vomiting, the astute clinician’s task is to assess whether the nausea and vomiting are mostly attributable to gastritis, withdrawal, or a combination. The best indicator is the history. If the patient is in withdrawal because they stopped drinking because of abdominal pain and vomiting, then gastritis is the likely etiology, and an anti-emetic and a GI cocktail are high yield. But if the patient stopped drinking due to lack of access to alcohol and the vomiting subsequently started with the withdrawal symptoms, then withdrawal is the likely etiology of the vomiting, and GABA agonist treatment will likely fix the vomiting. When the etiology is mixed, both treatment regimens are required.
	<br />		<br />
	<br />		<br />

AndyS at 17:07, 21 September 2019

2019-09-21T17:07:43Z

← Older revision		Revision as of 17:07, 21 September 2019
Line 9:		Line 9:
	<br />		<br />
	== '''Treatment Principles and Pearls''' ==		== '''Treatment Principles and Pearls''' ==
	* All patients complaining of alcohol withdrawal should have a breath alcohol level measured. This is truly the "fifth vital sign" in such patients. The presence of a measurable alcohol level does not rule-out withdrawal, but it does provide important information for management during this and/or future visits.		;Breath alcohol level
			:All patients complaining of alcohol withdrawal should have a breath alcohol level measured. This is truly the "fifth vital sign" in such patients. The presence of a measurable alcohol level does not rule-out withdrawal, but it does provide important information for management during this and/or future visits.
	<br />		<br />
	* Patients suffering alcohol withdrawal do not fall asleep while waiting to be seen. Alcohol withdrawal is a state of autonomic hyper-activity and hyper-alertness. Consequently, most withdrawing patients present with an inability to sleep. The patient who is drowsy or falling asleep is almost certainly intoxicated and pursuing some type of secondary gain (i.e. hangover prevention, a place to sleep, prescription medication abuse, etc.) or suffering from some other medical problem. The clinician should be alert to the co-existence of true medical problems which require treatment, but providing the desired secondary gain should be avoided.		;Intoxicated or sick patients
			:Patients suffering alcohol withdrawal do not fall asleep while waiting to be seen. Alcohol withdrawal is a state of autonomic hyper-activity and hyper-alertness. Consequently, most withdrawing patients present with an inability to sleep. The patient who is drowsy or falling asleep is almost certainly intoxicated and pursuing some type of secondary gain (i.e. hangover prevention, a place to sleep, prescription medication abuse, etc.) or suffering from some other medical problem. The clinician should be alert to the co-existence of true medical problems which require treatment, but providing the desired secondary gain should be avoided.
			<br />
			;Reasons to treat
			:Prevention of seizing is an inadequate clinical endpoint. If the pacing, tremulous patient is driving you and/or the staff crazy, then they are almost certainly doing the same to their housemates. The patient's access to a bed or couch to sleep on frequently depends upon adequate treatment of their withdrawal symptoms. If a patient is so irritating that everyone kicks them out, they will almost certainly bounce back to the ED. This alone is a reason to treat alcohol withdrawal. Patients who can sit still, keep down oral intake, and sleep are MUCH less likely to bounce back; and patients who are pacing, tremulous, and vomiting are almost guaranteed to bounce back.
			<br />
			;Etiology of vomiting
			:Alaska Natives have a very high rate of both chronic gastritis and/or H. pylori infection, and binge drinking frequently exacerbates or unmasks this condition. Yet nausea and vomiting are a common symptom of alcohol withdrawal in patients without any appreciable degree of gastritis. To efficiently treat the nausea and vomiting, the astute clinician’s task is to assess whether the nausea and vomiting are mostly attributable to gastritis, withdrawal, or a combination. The best indicator is the history. If the patient is in withdrawal because they stopped drinking because of abdominal pain and vomiting, then gastritis is the likely etiology, and an anti-emetic and a GI cocktail are high yield. But if the patient stopped drinking due to lack of access to alcohol and the vomiting started the withdrawal symptoms, then withdrawal is the likely etiology of the vomiting, and GABA agonist treatment will likely fix the vomiting.
	<br />		<br />
	* If the shaky, over-anxious patient is driving you or the staff crazy, then they are almost certainly doing the same to their housemates. The patient's access to a bed or couch to sleep on frequently depends upon adequate treatment of their withdrawal symptoms. If patient is so irritating that everyone kicks them out, they will almost certainly bounce back to the ED. This alone is a reason to treat alcohol withdrawal. Patients who can sit still, keep down oral intake, and sleep are MUCH less likely to bounce back.
	<br />		<br />
	== '''Phenobarbital''' ==		== '''Phenobarbital''' ==
	IV/IM phenobarbital is the preferred outpatient treatment of alcohol withdrawal at our facility.		IV/IM phenobarbital is the preferred outpatient treatment of alcohol withdrawal at our facility.
	See ''[[Phenobarbital for Alcohol Withdrawal]]'' for details.		See ''[[Phenobarbital for Alcohol Withdrawal]]'' for details.
			<br />
			<br />
			== '''Alcohol Withdrawal in Villages''' ==
	<br />		<br />
	<br />		<br />
	== '''References''' ==		== '''References''' ==
	<references />		<references />