Alcohol Withdrawal Management Protocol

Speaker Companion Guide — Teaching Notes & Anticipated Questions

Total Duration
45 Minutes
Slides
18
Target Audience
ED/Inpatient Teams
01
Title Slide
⏱ 2 min
🎤 Speaker Notes
  • Welcome attendees, introduce yourself
  • Confirm target audience mix (physicians, APPs, nurses)
  • Mention session is interactive — questions welcome throughout
  • Preview: "We'll cover assessment, treatment, escalation, and special cases"
  • Emphasize this is an evidence-based protocol, not institutional policy
Make eye contact with different sections of the room. This establishes rapport early.
02
Learning Objectives
⏱ 2 min
🎤 Speaker Notes
  • Read each objective aloud with emphasis on action verbs
  • Connect to practical scenarios: "When you see that CIWA of 24..."
  • Mention these map to post-session evaluation questions
  • Preview case study that will reinforce objectives 2-4
Objectives follow Bloom's taxonomy: Assess → Select → Implement → Recognize → Apply
❓ Anticipated Questions
Easy Will we get printed materials?
Yes, the full clinical guide and enrichment materials are available for download. You'll receive a link via email.
Easy Is this eligible for CME?
Yes, 1.0 AMA PRA Category 1 Credit™. Please complete the evaluation at session end.
03
The Clinical Problem
⏱ 4 min
🎤 Speaker Notes
  • Pause after each statistic — let numbers sink in
  • "1-4% mortality untreated" → emphasize this is preventable
  • Build tension before reveal button: "So why don't we just give everyone benzos?"
  • After reveal: Highlight 50% dose reduction — this is the key "win"
  • Mention that symptom-triggered is now standard of care per ASAM
Use vocal variety: quiet on mortality stats, energetic on the solution.
❓ Anticipated Questions
Medium What if the patient can't complete CIWA (altered, intubated)?
Excellent question. Use RASS (Richmond Agitation-Sedation Scale) or PAWS (Prediction of Alcohol Withdrawal Severity) in ICU. These don't require patient cooperation. We cover this in the Enrichment materials.
Hard Is there evidence symptom-triggered reduces DTs or just shortens stay?
Primary outcome was duration, but Daeppen et al. showed equivalent DT/seizure rates with less oversedation. The 2014 meta-analysis (Schmidt) confirmed no increase in adverse events with symptom-triggered approach.
04
CIWA-Ar Assessment Tool
⏱ 5 min
🎤 Speaker Notes
  • Point out that hallucinations are scored separately for each modality
  • Emphasize "orientation/clouding" is only 4 points but very important
  • Orientation loss suggests DTs — escalate immediately
  • Walk through reveal: "Here's how we interpret these scores..."
  • CIWA 15-24 threshold is where most complications occur
Ask the room: "What's the highest CIWA you've seen?" (Usually generates discussion)
❓ Anticipated Questions
Easy Do we need to score all 10 items every time?
Yes, per protocol. However, if tremor and sweating are zero for 4+ hours, some institutions allow abbreviated assessment. Check your local policy.
Medium How do we handle patients exaggerating symptoms for more medication?
This is common. CIWA includes objective measures (tremor, sweating) that can't be faked. If objective scores are low but subjective high, use clinical judgment. Remember: undertreated withdrawal is more dangerous than overmedication.
05
Risk Stratification Framework
⏱ 3 min
🎤 Speaker Notes
  • Connect to prior seizure/DT history — strongest predictor
  • High risk patients need more frequent monitoring, not necessarily higher doses
  • "Consider ICU" means start discharge planning if they need ICU
  • Reveal predictive factors: Emphasize these inform monitoring intensity
  • BAL >200 is counterintuitive — higher level = more severe dependence
❓ Anticipated Questions
Hard Why is BAL >200 a risk factor for complications?
Higher tolerance correlates with severity. A patient with BAL 250 who is awake has significant tolerance and likely more severe physiological dependence. This predicts worse withdrawal, not protection.
Medium Should all prior DT patients go to ICU?
Not automatically, but warrant step-down or high-observation beds with CIWA q1h and low threshold for escalation. Single prior uncomplicated DT with good response to treatment may be appropriate for monitored floor.
06
Clinical Workflow Algorithm
⏱ 4 min
🎤 Speaker Notes
  • Walk through each step slowly, pointing at workflow diagram
  • Step 5 "Escalate/DC" — emphasize it's a decision point
  • WARNING BOX: Pause, slow down, make eye contact
  • "Thiamine BEFORE glucose" — have audience repeat it back
  • Story: Wernicke case you saw (or heard of) if you have one
This is a safety-critical teaching point. Spend extra time here.
❓ Anticipated Questions
Medium What if glucose is critically low and we can't get thiamine immediately?
Prioritize glucose if <40 mg/dL, but give thiamine as soon as available (can be same line, different port). For mild hypoglycemia (40-70), wait for thiamine if <5 min away.
Easy Do we still give thiamine if the patient drinks fortified wines?
Yes. Fortified wines have minimal thiamine. Most alcoholics are deficient due to poor nutrition. The cost/risk of thiamine is negligible. Always give.
07
Benzodiazepine Selection Guide
⏱ 5 min
🎤 Speaker Notes
  • Table is dense — highlight key comparisons only
  • Lorazepam vs Chlordiazepoxide is the key decision point
  • "Intact liver only" for chlordiazepoxide — emphasize
  • Phenobarbital is NOT first-line — it's for refractory
  • Reveal: Use this for advanced learners who want pharmacology
Mnemonic: "Liver impaired? Lorazepam." (Both L's)
❓ Anticipated Questions
Hard Why is phenobarbital safer than high-dose benzos in ICU?
Different receptor site allows synergistic effect. Phenobarbital has linear pharmacokinetics (predictable levels) vs. benzodiazepine ceiling effect. Less respiratory depression per unit of withdrawal control. Can use without intubation in select cases.
Medium Is diazepam ever preferred over lorazepam?
Rapid onset situations: If immediate control needed (active hallucinations, severe agitation) and liver is intact, diazepam reaches peak faster. However, lorazepam is usually sufficient and safer.
08
Case Study: Maria
⏱ 5 min
🎤 Speaker Notes
  • Set scene: "It's 2 AM, ED is full, and Maria is trembling..."
  • Point to vitals: BP 168/94, HR 118 — this is autonomic hyperactivity
  • Low albumin + elevated LFTs = compensated cirrhosis likely
  • Before reveal, ask: "What would you choose?" (audience engagement)
  • After reveal: Emphasize why chlordiazepoxide is wrong answer
Case studies anchor abstract concepts to concrete decisions. Pause for questions mid-case if audience is engaged.
❓ Anticipated Questions
Medium Would you start phenobarbital given severity?
No, CIWA 22 with no prior seizures/DTs is appropriate for lorazepam protocol first. Phenobarbital reserved for CIWA >25 or >3 doses without improvement. Early phenobarbital increases length of stay without benefit.
Hard Should we give steroids for the possible cirrhosis?
No evidence for alcoholic hepatitis here. AST/ALT ratio 2:1 suggests alcohol but not acute hepatitis. If bilirubin >3 with elevated INR, consider Maddrey score and hepatology consult. Focus on withdrawal first.
09
Refractory Withdrawal & ICU Escalation
⏱ 4 min
🎤 Speaker Notes
  • "Refractory" = persistent symptoms despite adequate dosing
  • Point to warning box: These are "drop everything" criteria
  • Phenobarbital loading: emphasize this is ICU-level care
  • Dexmedetomidine adjunct: "Alpha-2 agonist, no respiratory depression"
  • Propofol and ketamine reserved for truly refractory cases
❓ Anticipated Questions
Medium When do we call anesthesia for airway?
Respiratory depression from benzos + escalating doses needed. If CIWA remains >20 despite high-dose lorazepam and phenobarbital, with decreasing respiratory drive, intubate BEFORE complete respiratory failure. Consider propofol for sedation continuity.
Hard Is there a role for ketamine in withdrawal?
Emerging evidence for refractory cases. NMDA antagonism may help with hyperexcitability. Use as adjunct to GABA agents, not monotherapy. Dose: 0.3-0.5 mg/kg bolus, then 0.1-0.5 mg/kg/hr infusion. Limited data, case series only.
10
Delirium Tremens
⏱ 4 min
🎤 Speaker Notes
  • "DTs" — emphasize it's not just shaking, it's a medical emergency
  • All three triad elements must be present
  • Mortality stats: contrast treated vs. untreated
  • Reveal: Walk through algorithm — ICU is step 1
  • "Antipsychotics alone lower seizure threshold" — critical safety point
❓ Anticipated Questions
Medium Can DTs occur without prior severe withdrawal?
Rare but yes. "Uncomplicated" withdrawal can progress to DTs, especially with intercurrent illness, infection, or head trauma. This is why CIWA monitoring continues even when improving.
Hard What about beta-blockers for autonomic symptoms in DTs?
Do not use as monotherapy. Masking tachycardia can hide CIWA progression. If needed for coronary protection, use short-acting agent (esmolol) with close monitoring, never as substitute for GABA therapy.
11
Edge Cases & Special Populations
⏱ 4 min
🎤 Speaker Notes
  • Pregnancy: Emphasize "untreated > treated" — don't withhold due to pregnancy
  • Elderly: "50% dose" — metabolism slows, confusion risk
  • Benzo use disorder: These patients need ICU, expect longer course
  • SSRI/Tramadol: Review med reconciliation importance
  • Ask: "Other edge cases you've encountered?"
❓ Anticipated Questions
Hard How do we manage concurrent opioid use disorder?
Continue buprenorphine or methadone. Do not precipitate withdrawal. Buprenorphine can be continued during alcohol withdrawal; no need to stop. Coordinate with addiction team for combined management.
Medium What about patients on chronic benzodiazepines for anxiety?
Maintain baseline dose, add lorazepam per CIWA protocol on top. These patients have tolerance and may need higher total doses. Monitor for respiratory depression but don't undertreat withdrawal.
12
Monitoring & Safety Protocol
⏱ 3 min
🎤 Speaker Notes
  • Table is reference material — don't read every cell
  • Highlight: CIWA q1-2h is labor-intensive but essential
  • Magnesium replacement: "The forgotten electrolyte"
  • Reveal: Specific replacement protocols for your institution
  • Fluid balance: "Alcoholics are often volume depleted but replace carefully"
❓ Anticipated Questions
Easy How long do we continue CIWA monitoring?
Continue until CIWA <10 x24h, then space to q4h x24h before discontinuing. Peak withdrawal is typically days 2-3, but can occur up to day 5 in severe dependence.
Medium Is telemetry required for all patients?
Not all, but most. Telemetry indicated for: CIWA >20, known CAD, significant tachycardia (>120), electrolyte abnormalities, or anticipated high-dose benzos. Floor bed with frequent checks acceptable for low-risk CIWA 10-15.
13
Implementation Checklist
⏱ 3 min
🎤 Speaker Notes
  • Interactive: Ask audience to mentally check off what they do now
  • Thiamine order: Emphasize "before" not "with"
  • Naltrexone timing at discharge — preview slide 15
  • Reveal: Nursing training requirements for CIWA reliability
  • Mention your institution's current training status
❓ Anticipated Questions
Medium Do we need addiction psychiatry consult for every patient?
Ideal: yes. Realistic: at least high-risk. Consult recommended for: prior DTs/seizures, concurrent SUD, psychiatric comorbidity, or if considering naltrexone initiation. May be outpatient referral for uncomplicated cases.
Hard What if our institution doesn't stock phenobarbital?
Advocate for formulary addition. Alternative: High-dose lorazepam infusion with ICU monitoring. But phenobarbital is ASAM-recommended for refractory cases; consider transfer to tertiary center if unavailable.
14
Discharge Criteria & Planning
⏱ 3 min
🎤 Speaker Notes
  • "CIWA <10 x24h" — emphasize the 24-hour requirement
  • No benzo prescriptions: This is a common error
  • "Bridge to treatment" — what % of your patients actually follow up?
  • Cards contrast: Green for go, red for stay
  • Social determinants often drive discharge decisions
❓ Anticipated Questions
Medium Can we discharge with a benzo taper for outpatients?
Only with addiction psychiatry oversight. Risk of diversion and ongoing dependence. If needed, short taper (3-5 days) with daily dispensing or witnessed dosing. Prefer residential treatment for ongoing needs.
Hard What about patients who leave AMA with CIWA still elevated?
Risk stratify. If CIWA >15, consider emergency hold if state law permits. Otherwise, provide clear return precautions, ensure shelter/safe location, and consider observation unit if available. Document discussion of risks.
15
Post-Withdrawal: AUD Pharmacotherapy
⏱ 3 min
🎤 Speaker Notes
  • Shift from acute to maintenance — "withdrawal is just the beginning"
  • Naltrexone timing: "Once CIWA <10 x24h" — not before
  • Disulfiram: "Motivation-dependent" — compliance is everything
  • Reveal: Offer this for learners wanting depth on selection
  • Topiramate: Mention off-label but commonly used
❓ Anticipated Questions
Hard Should naltrexone be started before discharge or outpatient?
Advantage to inpatient start: Ensures opioid-free status, provides 1-2 doses before discharge, improves adherence. Give first dose 24h after last CIWA >10. Requires addiction psych or trained prescriber.
Medium What about gabapentin for alcohol use disorder?
Emerging evidence supports efficacy, but not first-line. May be considered if naltrexone/acamprosate contraindicated or failed. Dose: 300-1800mg divided BID-TID. Monitor for sedation, especially with benzodiazepine history.
16
Key Takeaways
⏱ 2 min
🎤 Speaker Notes
  • Summary slide — recap the journey
  • Point to cards: "Assessment, Treatment, Escalation, Discharge"
  • Final statement: "Untreated 15-20%, treated <1%"
  • Call to action: "Use this protocol. Train your teams."
  • Pause before Q&A
❓ Anticipated Questions
Medium How do we implement this protocol system-wide?
Phased approach: (1) Champion identification, (2) EHR order set build, (3) Nursing education with competency validation, (4) Pilot unit, (5) Spread. Allow 6-12 months for full implementation. Metrics: CIWA completion rates, benzo dosing, LOS.
17
References & Further Reading
⏱ 1 min
🎤 Speaker Notes
  • Read Saitz and Daeppen as seminal trials
  • ASAM guideline is the current standard
  • Stahl for pharmacology depth
  • Mention Enrichment materials have full reference list
  • Quick transition to Q&A
❓ Anticipated Questions
Easy Are slides available for download?
Yes, all materials including speaker notes, clinical guide, and enrichment resources will be available on the portal within 24 hours.
18
Thank You / Questions
⏱ 5 min
🎤 Speaker Notes
  • Thank audience for attention
  • Invite questions — "What wasn't clear?"
  • Redirect off-topic questions: "Let's discuss offline"
  • Close with thanks to organizers
  • Remain available for 1-on-1 questions after
If no questions, ask: "What's one thing you'll change in your practice tomorrow?"