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Alcohol Intoxication Withdrawal, Adult ED/UCC Order Set
20745Bond
Alcohol Intoxication Withdrawal, Adult
Select orders by replacing a () in the associated box
20745Bond (Rev2021-11v2)
Last Name (Legal) First Name (Legal)
Preferred Name Last First DOB(dd-Mon-yyyy)
PHN ULI Same as PHN MRN
Administrative Gender Male Female
Non-binary/Prefer not to disclose (X) Unknown
Goals of Care
Conversations leading to the ordering of a Goals of Care Designation (GCD) should take place as early as possible in a
patient’s course of care. The Goals of Care Designation is created, or the previous GCD is armed or changed result-
ing from this conversation with the patient or, where appropriate, the Alternate Decision-Maker.
Complete the Goals of Care Designation (GCD) Order Set within your electronic system, or if using paper process, com-
plete the Provincial Goals of Care Designation (GCD) paper form (http://www.albertahealthservices.ca/frm-103547.pdf)
Intravenous Fluid Orders
o Intravenous Cannula - Insert
o Saline lock IV, ush with 2 to 5 mL NaCl 0.9% every 12 hours
IV Bolus
o NaCl 0.9% _____ mL over _____ hour(s)
o lactated ringers _________ mL over _____ hour(s)
IV Maintenance
o NaCl 0.9% infusion ______ mL/hour, reassess after _____ hours
o lactated ringers infusion ______ mL/hour, reassess after _____ hours
Laboratory Investigations
The anion gap (AG) can be calculated as, Na+ - (Cl- + HCO3-) with a normal range of 4 to 12 mmol/L. An elevated gap
in this population should lead clinicians to consider alcoholic ketoacidosis.
The osmol gap (OG) is calculated as the dierence between measured serum osmolality and calculated osmolality.
Calculated osmolality = 2 x Na+ + glucose + urea + [ETOH x 1.25] (all measured in mmol/L). A normal gap is generally
less than 10 mOsm/kg. Both ketones and lactate will contribute to an osmolar gap. An unexplained gap of greater than
10 mOsm/kg could suggest a toxic alcohol co-ingestion.
Hematology
o Complete Blood Count (CBC)
o PT INR
Chemistry
o
Electrolytes (Na, K, Cl, CO2) o Glucose
o Creatinine o Urea
o ALT o Bilirubin Total
o GGT o Lipase
o Calcium o Magnesium
o Phosphorus o Albumin
Blood Gases
o Blood Gas Venous
o Blood Gas Arterial
Therapeutic Drug Monitoring and Toxicology
o
Ethanol o Methanol
o Acetaminophen o Isopropanol
o Salicylate o Ethylene Glycol
o Osmolality
Prescriber Signature Date (dd-Mon-yyyy) Time (hh:mm)
Page 1 of 4
Alcohol Intoxication Withdrawal, Adult
Select orders by replacing a () in the associated box
20745Bond (Rev2021-11v2)
Last Name (Legal) First Name (Legal)
Preferred Name Last First DOB(dd-Mon-yyyy)
PHN ULI Same as PHN MRN
Administrative Gender Male Female
Non-binary/Prefer not to disclose (X) Unknown
Laboratory Investigations (continued)
o Urinalysis Random
o Pregnancy Test, Urine
Other Labs
(based on presentation needs of the patient)
o ____________________________________________________________________________________
o ____________________________________________________________________________________
o ____________________________________________________________________________________
Diagnostic Imaging
o Chest X-Ray 2 projections (posterior-anterior & lateral)
o Chest X-Ray 1 projection: Portable (posterior-anterior)
o CT Head (non–enhanced)
Other Investigations
o Electrocardiogram - 12 Lead (ECG)
Medications
Thiamine (recommended for chronically malnourished alcoholics to prevent Wernicke’s)
o Vitamin B1 (thiamine) ______ mg IV every 24 hours (recommended dosage 300 mg)
OR
o Vitamin B1 (thiamine) ______ mg PO every 24 hours (may give orally once patient tolerating regular diet,
recommended dosage 300 mg)
For Wernicke’s encephalopathy (oculomotor dysfunction, ataxia, encephalopathy:
o Vitamin B1 (thiamine) 300 mg IV every 8 hours x 3 days AND THEN 300 mg IV/PO every 8 hours x 5 days
Other Vitamins
o folic acid 1 mg PO daily for 5 days and then reassess
OR
o folic acid 1 mg IV daily if NPO for 5 days and then reassess
o vitamins multiple with minerals 2 tabs PO every 24 hours
OR
o vitamins multiple 10 mL in a 1 liter bag of IV solution once (only for those with signs of obvious malnutrition)
Electrolyte Replacement
o magnesium sulphate 2 g IV once
(consider if hypomagnesic/hypokalemic or cardiac dysrhythmia, or neuromuscular
irritability)
o potassium chloride 10 mmol in 100 mL sterile water x ___ doses, each bag to be infused over 1 hour
o potassium chloride SR tabs 40 mmol PO once
(each tab is 1500 mg = 20 mmol; 2 tablets = 40 mmol)
OR
o potassium chloride liquid 40 mmol PO once (each mL is 100 mg = 1.33 mmol; 30 mL = 40 mmol)
Other Medications
o ____________________________________________________________________________________
o ____________________________________________________________________________________
o ____________________________________________________________________________________
Prescriber Signature Date
(dd-Mon-yyyy) Time (hh:mm)
Page 2 of 4
Alcohol Intoxication Withdrawal, Adult
Select orders by replacing a () in the associated box
20745Bond (Rev2021-11v2)
Last Name (Legal) First Name (Legal)
Preferred Name Last First DOB(dd-Mon-yyyy)
PHN ULI Same as PHN MRN
Administrative Gender Male Female
Non-binary/Prefer not to disclose (X) Unknown
Medications (continued)
Benzodiazepines
Recommend an hourly symptom-based regimen, using the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) score or
the short scale of withdrawal severity (SHOT) to assess medication initiation/continuation. The recommended goal is to achieve light
somnolence OR to achieve minimal to moderate sedation.
LORazepam is the drug of choice for the elderly, or patients with COPD or severe liver disease.
ChlordiazePOXIDE should not be used for elderly patients or those with hepatic impairment.
*See scoring tool on side B of this page*
o Clinical Institute Withdrawal Assessment for Alcohol: to be completed with administration of
benzodiazepines and reassess at a minimum of every 1 hour. Notify physician when CIWA-Ar score is
10 or less for 3 consecutive assessments to reassess monitoring/disposition planning.
Following initial assessment (loading dose recommendations):
If initial CIWA-Ar Score greater than 19 – Severe agitation - (choose ONE)
o diazepam 20 mg IV/PO once
o diazepam 10 mg IV/PO once
AND THEN
o diazepam ______ mg IV/PO every 15 minutes PRN to achieve a CIWA-Ar less than 19;
reassess CIWA-Ar 1 hour following administration of rst dose
o LORazepam 4 mg IV/SL/PO once
o LORazepam 2 mg IV/SL/PO once
AND THEN
o LORazepam __ mg IV/SL/PO every 15 minutes PRN to achieve a CIWA-Ar less than 19;
reassess CIWA-Ar 1 hour following administration of rst dose
If initial CIWA-Ar Score 10 to 19 – Moderate agitation - (choose ONE)
o diazepam 10 mg IV/PO once
o diazepam 5 mg IV/PO once
o LORazepam 4 mg IV/SL/PO once
o LORazepam 2 mg IV/SL/PO once
For subsequent medication dosing, adjust based on hourly CIWA-Ar scores:
If CIWA-Ar Score greater than 19 – Severe agitation - (choose ONE)
o diazepam 20 mg IV/PO every 1 hour PRN for CIWA-Ar score greater than 19
o diazepam 10 mg IV/PO every 1 hour PRN for CIWA-Ar score greater than 19
o LORazepam 4 mg IV/SL/PO every 1 hour PRN for CIWA-Ar score greater than 19
o LORazepam 2 mg IV/SL/PO every 1 hour PRN for CIWA-Ar score greater than 19
If CIWA-Ar Score 10 to 19 – Moderate agitation - (choose ONE)
o diazepam 10 mg IV/PO every 1 hour PRN for CIWA-Ar score 10 to 19
o diazepam 5 mg IV/PO every 1 hour PRN for CIWA-Ar score 10 to 19
o LORazepam 2 mg IV/SL/PO every 1 hour PRN for CIWA-Ar score 10 to 19
o LORazepam 1 mg IV/SL/PO every 1 hour PRN for CIWA-Ar score 10 to 19
If CIWA-Ar Score 0 – 9 for 4 consecutive hours may switch to PRN orders - (choose ONE)
o diazepam 5 to 10 mg PO every 6 hours PRN to control residual symptoms
o LORazepam 2 to 4 mg PO every 6 hours PRN to control residual symptoms
o chlordiazePOXIDE 25 to 50 mg PO every 6 hours PRN to control residual symptoms
Prescriber Signature Date
(dd-Mon-yyyy) Time (hh:mm)
Page 3 of 4 - Side A
Page 3 of 4 - Side B
Alcohol Withdrawal Assessment Scoring Guidelines (CIWA-Ar)1
Rate on scale as indicated by numbers in each section
Nausea/Vomiting
0 – None
1 – Mild nausea and vomiting
2
3
4 – Intermittent nausea
5
6
7 – Constant nausea and frequent heaves and vomiting
Tremors Patient to extend arms & spread ngers
0 – No Tremor
1 – Not visible but can be felt ngertip to ngertip
2
3
4 – Moderate with arms extended
5
6
7 – Severe, even with arms not extended
Anxiety
0 – No anxiety, patient at ease
1 – Mild anxious
2
3
4 – Moderately anxious or guarded, so inferred anxiety
5
6
7 – Equivalent to acute panic states seen in severe
delirium or acute schizophrenic reactions
Agitation
0 – Normal Activity
1 – Somewhat normal activity
2
3
4 – Moderately dgety and restless
5
6
7 – Paces back and forth or constantly thrashes about
Paroxysmal Sweats
0 – No sweats
1 – Barely perceptible sweating, palms moist
2
3
4 – Beads of sweat obvious on forehead
5
6
7 – Drenching sweats
Orientation and Clouding of Sensorium
Ask: What day is this? Where are you? Who am I?
Rate on scale 0 – 4
0 – Orientated
1 – Cannot do serial additions or is uncertain about the
date
2 – Disorientated to date by no more than 2 calendar days
3 – Disorientated to date by more than 2 calendar days
4 – Disorientated to place/and or person
Tactile disturbances Ask: Have you experienced any
itching, pins &needles, burning or numbness, or a feeling
of bugs crawling on or under your skin?
0 – None
1 – Very Mild itching, pins & needles, burning or numbness
2 – Mild itching, pins & needles, burning or numbness
3 – Moderate itching, pins & needles, burning or numbness
4 – Moderate hallucinations
5 – Severe hallucinations
7 – Continuous hallucinations
Auditory Disturbances Ask: Are you more aware of
sounds around you? Are they harsh? Do they startle you?
Do you hear anything that disturbs you or that you know
isn’t there?
0 – None Present
1 – Very middle harshness or ability to startle
2 – Mild harshness or ability to startle
3 – Moderate harshness or ability to startle
4 – Moderate hallucinations
5 – Severe hallucinations
7 – Continuous hallucinations
Visual disturbances Ask: Does the light appear to be too
bright? Is its color dierent than normal? Does it hurt your
eyes? Are you seeing anything that disturbs your or that
you know isn’t there?
0 – Not Present
1 – Very mild sensitivity
2 – Mild sensitivity
3 – Moderate sensitivity
4 – Moderate hallucinations
5 – Severe hallucinations
7 – Continuous hallucinations
Headache Ask: Does your head feel dierent than usual?
Does it feel like there is a band around your head?
(Do not
rate dizziness or light headedness)
0 – Not Present
1 – Very mild
2 – Mild
3 – Moderate
4 – Moderate severe
5 – Severe
6 – Very severe
7 – Extremely severe
Adapted from Sullivan JT, Sykora K, Schneiderman J, Naranjo CA, Sellers. Assessment of alcohol withdrawal: the revised Clinical
Institute Withdrawal Assessment for Alcohol scale (CIWA-Ar). Br Journal of Addict. 84(11):1353-1357.
Alcohol Intoxication Withdrawal, Adult
Select orders by replacing a () in the associated box
20745Bond (Rev2021-11v2)
Last Name (Legal) First Name (Legal)
Preferred Name Last First DOB(dd-Mon-yyyy)
PHN ULI Same as PHN MRN
Administrative Gender Male Female
Non-binary/Prefer not to disclose (X) Unknown
Medications (continued)
For hallucinations not controlled by adequate doses of benzodiazepines
o haloperidol ______ mg IM/PO/IV every ______ hour(s) PRN
AND
(if required to prevent or manage a dystonic reaction to haloperidol)
o benzotropine 1 mg IM/IV once
OR
o benzotropine 2 mg IM/IV once
o diphenhydrAMINE 25 mg IM/IV once
OR
o diphenhydrAMINE 50 mg IM/IV once
Other medications as required
o
metocloproamide 5 to 10 mg IV/PO once and then metocloproamide 5 to 10 mg IV/PO every 4 hours PRN
OR
o ondansetron 4 mg IV once and then ondansetron 4 mg IV every 8 hours PRN
OR
o ondansetron 4 to 8 mg PO once and then ondansetron 4 to 8 mg PO every 8 hours PRN
o lidocaine viscous 2% / antacid liquid 30 mL PO once (
5 mL lidocaine viscous and 25 mL antacid liquid)
o _____________________________
Patient Care
Monitoring
o Vital Signs (respiratory rate, pulse, blood pressure, temperature, oxygen saturation)
o as per Provincial Assessment and Reassessment of Patients Guideline
o every ____ hour(s) o manual o automatic
o every ____ minutes o manual o automatic
o Glasgow Coma Scale (GCS), pupillary size and reaction to light with reassessments
o as per local standards
o every ____ hour(s)
o every ____ minutes
o Notify physician if patient’s GCS decreases by two or more points
o Measure and record Intake and Output every ______ hour(s)
Respiratory Care
o O2 Therapy @ _______ LPM via ___________to maintain O2 sat greater than or equal to 90%
o Notify physician if O2 ow required to be increased by greater than 2 L to maintain the same level of
oxygenation or if there is a progressive increase in the work of breathing
Activity
o Bedrest
(recommended)
o Activity as Tolerated
o Other Activity: ________________________________________________________________________
Safety and Precautions
o Soft physical restraints o Remove hand sanitizer from room
Diet/Nutrition
o NPO o NPO: May Take Meds
o Regular Diet o Other Diet: ______________________________
Prescriber Signature Date
(dd-Mon-yyyy) Time (hh:mm)
Page 4 of 4
